Akron Zoo
MEMBERSHIP REQUEST
Cuyahoga DD Family Supports Program (FSP) Funding
INDIVIDUAL RECEIVING FSP SERVICES:
First Name of Child/Individual
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Last Name of Child/Individual
*
Date of Birth
*
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Month
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Day
Year
Date
Date of Birth
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Year
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Month
Day
Date
SELECT ANNUAL MEMBERSHIP LEVEL:
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FAMILY $110.00: Membership for two named adults and dependent children or grandchildren under the age of 18
FAMILY PLUS $130.00: Membership for two named adults and dependent children or grandchildren under the age of 18 plus one named or unnamed guest. Unnamed guest cannot use the membership without one of the named adults on the card being present.
FAMILY DELUXE $160.00: Membership for two named adults and dependent children or grandchildren under the age of 18 plus two named or unnamed guests per visit. Unnamed guests cannot use the membership without one of the named adults on the card being present.
Are there other individuals in your household receiving FSP services?
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Yes
No
Are there other individuals in your household receiving FSP services?
Yes
No
Do you want the cost of this membership to be split up amongst multiple individuals receiving FSP services?
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Yes
No
Do you want the cost of this membership to be split up amongst multiple individuals receiving FSP services?
Yes
No
Please list all the individuals whose FSP funding is to be used towards this membership, and the amount for each.
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ADULT FAMILY MEMBER(S) (Limit of 2) - Please note, if you do not list a 2nd Adult Family Member at the time of application, the Akron Zoo will forfeit that spot:
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PHONE NUMBER:
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Please enter a valid phone number.
E-MAIL:
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Confirmation Email
example@example.com
Number of children in the household (under the age of 18)
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ADDRESS (Include Apt. #/Suite # when applicable)
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
NAMED GUEST(S) (Family Plus - 1 allowed/ Family Deluxe - 2 allowed)
Guest 1
First Name
Last Name
Guest 2
First Name
Last Name
*
I give permission for Neon to share details about this FSP funding request with the vendor listed on this form. I understand that it is my responsibility to verify my available Family Supports funding balance, and I will be utilizing this funding to cover this activity.
Membership changes/cancellations:
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I understand that once my membership has been purchased, I CANNOT change or cancel my membership request. I also understand that the prices listed are not guaranteed and are subject to change at anytime. I agree to follow the policies of this vendor, including vendor pricing, cancellation policies, and other possible requirements.
SIGNATURE:
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SUBMISSION DATE:
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Year
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Month
Day
Submit
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