Membership
Update

Membership Update

Purpose

The Down Syndrome Association of Jacksonville is committed to providing quality information to its members. Our goal is to ensure that all interested members are receiving information in a timely and cost effective manner. 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

Prefer email or mail?	Email Mail	eTap #:
Mother's Full Name:		Mother's Occupation:
Father's Full Name:		Father's Occupation:
Address:
City:		State:
Zip:		County:
Home Phone:		Cell Phone:
Work Phone:
Email:	N/A
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.)

Full Name of Individual with DS:
Date Of Birth of Individual with DS:	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
Were you diagnosed...	Pre-Natal? - or - Post-Natal?
If you were delivered in Jacksonville (or the surrounding area), which hospital?

Did you receive the DSAJ blue welcome packet?	Yes No
May we share your information with other DSAJ support coordinators?	Yes No
School, if applicable:
Would you like information on any of the following programs:
Lil' Stars (newborn-5) Shining Stars (6-12) Teens (13-17) Adults (18 +)
D.A.D.S. Soccer Basketball (12+) Cheerleading (8+)
Wellness/Fitness (16+) Computer Tutoring (16 months +) Speech Therapy
Would you be interested in volunteering:	Yes No
How did you hear about the DSAJ?
Other comments:

By submitting this form you consent that the DSAJ may display, publish and share in any way, photos of your child/family.	Yes No
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.