Lake Metroparks Farm Park
MEMBERSHIP APPLICATION
Cuyahoga DD Family Supports Program (FSP) Funding
Membership Includes:
Includes 2 adults living at the same address (both names must be on the card) or a single parent and one adult guest and up to 5 children younger than 18 years of age.
Individual Receiving FSP Services:
First Name of Child/Individual
*
Last Name of Child/Individual
*
Date of Birth
*
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Month
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Day
Year
Date
Please choose an annual membership:
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Family: $75- Two adults living at the same address (both names must be on the card) or a single parent and one adult guest and up to five children (younger than 18 years)
Family + 2: $100- Same as Family, plus two additional guests on each visit
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.
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ADULT(S) INFORMATION: (maximum of 2)
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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
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Submission Date
*
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Year
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Month
Day
Date
SUBMIT
Should be Empty: