Rock and Roll Hall of Fame
MEMBERSHIP REQUEST
Cuyahoga DD Family Supports Program (FSP) Funding
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
Please Choose a membership:
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$100 DUET: 1 member plus 1 guest per visit
$180 ROLLER: 2 members plus 2 guests per visit OR 2 members plus all kids in the household (age 18 and under)
Date of Birth
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Year
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Month
Day
Date
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.
*
Adult Name
*
Adult First Name
Adult Last Name
Adult Information:
*
E-mail
*
Confirmation Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone Number
*
*
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
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Month
Day
Date
SUBMIT
Should be Empty: