Application

You can fill out the form below or download an application and mail it in.

After submitting the form below, you will have the opportunity to donate online, or you may mail in a check.

DSNMC Membership Application 2011

* required fields

Select one	New Member Renewal Withdraw Name
*Parent Name(s)
Name of Child with Down Syndrome
Date of Birth	(mm/dd/yyyy)
Names & of ages of Siblings
*Address
*City, State, Zip
*Phone Number
*Email Address
Title and/or Organization (if applicable)
Does the above information differ from the directory and need to be updated?	Yes No
Explain briefly any medical, educational or other issues you have experienced with your child that you could help another parent through
Schools your child has attended
Names of medical or other professionals you would recommend
Do you prefer your communications in English or Spanish?	English Spanish
For newsletters, do you prefer an electronic or paper version?	Electronic Paper version
Which best describes you? Select all those that apply.	Self-advocate (person with Down syndrome) Parent/guardian of person with Down syndrome Extended Family or Friend Genetics professional Therapist (e.g. PT, OT, CT, etc.) OB/GYN Midwife, Doula or Birthing Professional Pediatrician Nurse Educator Other:
Please rank your top 3 reasons for joining DSNMC	New to this area Prenatal screening or diagnosis Recent birth/adoption of child with Down syndrome Social opportunities Education & information Advocacy & legislative involvement Guidance for government programs & services Other:
Are you interested in joining a committee/volunteering? If yes, which one?