Stan Hywet Hall and Gardens
ANNUAL FAMILY MEMBERSHIP
Cuyahoga DD Family Supports Program (FSP) Funding
Individual Receiving FSP Services:
First Name of Child/Individual
*
Last Name of Child/Individual
*
Date of Birth
*
-
Month
-
Day
Year
Date
Membership type:
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$100 (online price) 2 adults and up to 7 children under 18
Are there other individuals in your household receiving FSP services?
*
Yes
No
Do you want the cost of this membership to be split up amongst multiple individuals receiving FSP services?
*
Yes
No
Please list all the FSP individuals whose FSP funding is to be used towards this membership, and the amount for each.
*
ADULT(S) INFORMATION (maximum of 2):
*
Address (include Apt#, Suite, etc. where applicable)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
Confirmation Email
example@example.com
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
*
-
Year
-
Month
Day
Date
SUBMIT
Should be Empty: