The Cleveland Museum of Art
MEMBERSHIP REQUEST FORM
Cuyahoga DD Family Supports Program (FSP) Funding
INDIVIDUAL RECEIVING FSP SERVICES:
First Name of Child/Individual
*
Last Name of Child/Individual
*
Date of Birth
*
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Month
-
Day
Year
SELECT MEMBERSHIP:
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FRIEND $65: Includes 1 adult (19+) and children (2-18) in the same household
PARTNER $90: Includes 2 adults (19+) and children (2-18) in the same household
AMBASSADOR $140: Members at the Ambassador level enjoy nationwide reciprocity with participating institutions with the benefits of membership for two adults and children.
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 FSP individuals whose FSP funding is to be used towards this membership, and the amount for each.
*
SELECT MEMBERSHIP:
*
PARTNER $90: Includes 2 adults (19+) and children (2-18) in the same household
AMBASSADOR $140: Members at the Ambassador level enjoy nationwide reciprocity with participating institutions with the benefits of membership for two adults and children.
ADULT INFORMATION:
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone Number
*
E-mail
*
Confirmation Email
example@example.com
*
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:
*
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
*
Submission Date
*
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Year
-
Month
Day
Submit
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