Get Air- Middleburg Heights

Get Air - Middleburg Heights

MEMBERSHIP REQUEST
Cuyahoga DD Family Supports Program (FSP) Funding
Please complete a separate form for each family member receiving Family Supports funding who you would like a membership for. After submission of this form, you will be asked if you would like to complete an additional form.

Note: If requesting a membership for a child, they must be able to walk on their own in order for a membership to be purchased
INDIVIDUAL RECEIVING FSP SERVICES:
First Name of Child/Individual*
Last Name of Child/Individual*
Child/Individual Date of Birth*

MonthDayYear
Date
SELECT ANNUAL MEMBERSHIP LEVEL - PLEASE MAKE SURE TO MEASURE YOUR CHILD. CHOOSING THE WRONG MEMBERSHIP WILL CAUSE DELAYS IN PURCHASING:*

Ultimate Little Air Jumpers (under 46” tall) ‐ $179.99 plus taxUltimate Big Air Jumpers (46” or taller) $199.99 plus tax
ADULT INFORMATION:
Adult First NameAdult Last Name
Address*

Street Address, (Include Apt #, Up/Down, etc)

Street Address Line 2

CityState / Province

Postal / Zip Code
PHONE NUMBER:*
Please enter a valid phone number.
E-MAIL:*

Confirmation Emailexample@example.com
Acknowledgement:*

I understand that if requesting this membership for a child, the child MUST BE ABLE to walk on their own without assistance. 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:*

Clear
SUBMISSION DATE:*

YearMonthDay
Should be Empty:

Get Air - Middleburg Heights

Cuyahoga DD Family Supports Program (FSP) Funding

INDIVIDUAL RECEIVING FSP SERVICES:

ADULT INFORMATION: