Membership Update

Purpose

Down Syndrome Association of Jacksonville is committed to providing quality information to its members and believes that the preparation and delivery of newsletters, calendars of events and annual reports plays a big role in carrying out this commitment. In an effort to optimize this objective, we are in the process of updating the information in our database. Our goal is to ensure that all interested members are receiving information in a timely and cost effective manner. One objective that we hope to achieve is to deliver as much information as possible by email. This will result in members receiving information quicker and will save the Down Syndrome Association of Jacksonville the significant costs associated with printing and delivering information by regular mail. Therefore, we strongly encourage all members to opt out of receiving information by regular mail and elect to receive this information electronically. We value your time and hope that you will take a minute to complete this form so that we can continue our goal of providing quality information to all of our members. Thank you for supporting the Down Syndrome Association of Jacksonville and we look forward to serving you in the future.

Submission of this form is required to remain in our database. If you no longer wish to be in our database, simply enter your first and last name and check the box next to "Remove Me From Your Database," then submit the form.

Remove Me From Your Database:

Fields In Bold Are Required

Electronic Mailing List

Would you prefer to receive mailings electronically? Yes No
You may return to our regular mailing list in the future by notifying us on your request.

Mailing Address

Last Name:		First Name(s):
Email:	N/A
Preferred Phone:	Home Cell Work	Alternate Phone:	Home Cell Work
Address:
City:		State:	Zip:
Occupation:
Relationship To Individual With Down Syndrome (Please Check All That Apply):
Parent Professional Grandparent Educator Self-Advocate
Sibling No Relation Loved one of an individual who is now deceased
Other:

Individual With Down Syndrome

If you indicated you are the parent or guardian of an individual with Down syndrome please provide the following information. (If you selected "No Relation" above, this section is not required.

Last Name:		First Name:
Date Of Birth:	Month: 00 01 02 03 04 05 06 07 08 09 10 11 12 Day: 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year (yyyy):
Gender:	Female Male Declined
When were you diagnosed?	Pre-Natal Post-Natal

Is this individual a member of Lil' Stars, Shining Stars, Young Adult or Adult Groups?		Yes No
If no, would she/he be interested in learning more about groups?		Yes No
If yes, which groups?	Lil' Stars Shining Stars Young Adult Group Adult Group
Preferred Method of Contact:	Email: N/A	Phone: N/A

Volunteer

Are you or someone in your household interested in volunteering?		Yes No
In what area(s) would you be interested in volunteering?		Office Buddy Walk Golf Tournament

Preferred Method of Contact:

Email: N/A

Phone: N/A

Sharing

May we share your information with DSAJ family support?

Yes No

 

Any additional comments or information?

Security Code:

Thank you for your time and participation in completion of this form.
Down Syndrome Association of Jacksonville
Member Services
All information provided will be kept confidential & private, unless indicated by you on this form.