Akron Children's Museum

Akron Children's Museum

MEMBERSHIP REQUEST
Cuyahoga DD Family Supports Program (FSP) Funding
INDIVIDUAL RECEIVING FSP SERVICES:
First Name of Child/Individual*
Last Name of Child/Individual*
Date of Birth*

MonthDayYear
Date
Select Annual Membership Level:*

$ 65 - LEVEL 1: Up to 3 named individuals$ 77 - LEVEL 1 PLUS: 4 named individuals$ 90 - LEVEL 2: Up to 5 named individuals$102 - LEVEL 2 PLUS: 6 named individuals$150 - LEVEL 3: Up to 8 named individuals$162 - LEVEL 3 PLUS: 9 named individuals
Are there other individuals in your household receiving FSP services?*

YesNo
Do you want the cost of this membership to be split up amongst multiple individuals receiving FSP services?*

YesNo
Please list all the individuals whose FSP funding is to be used towards this membership, and the amount for each.*
Primary Adult Family Member:*

First NameLast Name
Address*

Street Address (Include Apt #, Up/Down, etc)

Street Address Line 2

CityState

Zip Code
PHONE NUMBER:*
Please enter a valid phone number.
E-MAIL:*
example@example.com
Membership changes/cancellations:*

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 any time.
SIGNATURE:*

Clear
SUBMISSION DATE:*

YearMonthDay
Should be Empty:

Cuyahoga DD Family Supports Program (FSP) Funding