COLUMBUS ZOO & AQUARIUM
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
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Date of Birth
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Month
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Day
Year
Date
Select Annual Membership Level:
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Family Membership ‐ $194.99 - Admits up to two (2) primary named adult members in the same household plus either dependent children OR grandchildren up to age 21 (not both) to the Columbus Zoo and Aquarium.
Family Plus Membership ‐ $284.99 - Admits two (2) primary named adult members in the same household plus either dependent children OR grandchildren up to age 21 (not both) to the Columbus Zoo and Aquarium. This membership also includes up to two named or unnamed guests. Additional named adults can visit independently from the primary named adult members. Unnamed guests can only visit the Zoo with the primary named adult members present. Primary defined as spouse/domestic partner. If you have questions, please call the membership office.
Are there other individuals in your household 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?
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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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Primary Adult in same household #1:
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First Name
Last Name
Would you like to add a second Primary Adult in same household?
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Yes
No
Primary Adult in same household #2:
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First Name
Last Name
Address
*
Street Address (Include Apt #, Up/Down, etc)
Street Address Line 2
City
State / Province
Postal / Zip Code
PHONE NUMBER:
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Please enter a valid phone number.
E-MAIL:
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example@example.com
Signature:
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Clear
SUBMISSION DATE:
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Year
-
Month
Day
Submit
Should be Empty: