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Holiday Gift Program 2023
Name
*
First Name
Last Name
Email
*
Verify Email
*
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Phone
*
I am a
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Parent of a child with Down syndrome
Caregiver of an individual with Down syndrome
Ethnicity of Individual with Down Syndrome
*
This information is used for grant writing purposes.
select one
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Prefer Not To Answer
Household Income
*
This information is used for grant writing purposes.
select one
$1 to $24 999
$25,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $149,999
$150,000 and greater
Prefer not to answer
How many adults are in your household?
Adult #1 Name
Adult #2 Name
Please check ALL THAT APPLY:
I am an existing DSA member that has a child with Down syndrome
My family's household income is at or below (numbers based on 200% of Federal Poverty Level guidelines) 1 person household / $25,520, 2 person household / $34,480, 3 person household / $43,440, 4 person household / $52,400, 5 person household/ $61,360, 6 person household / $70,320, 7 person household / $79,280, 8 person household / $88,240, additional persons, add $8,960 per person
I have extenuating circumstances or unforeseen conditions that significantly impacts my ability to pay for program costs. If so, please expand below.
Please explain any extenuating circumstances.
I hereby declare that the above particulars and information availed above are true to the best of my knowledge and the same shall form the basis of any arrangement for any financial assistance, in any granted to me.
I Agree
Family Wish Lists:
Individual with Down syndrome
*
First Name
Last Name
Birthday of Individual with Down Syndrome
*
(mm/dd/yyyy)
Gender
*
Female
Male
Please provide a DETAILED wish list (ranging from $35-$50 per person), including sizing for clothing and shoes. DSA will not accept gift cards as an acceptable wish list item.
*
Example: Baby alive doll (blonde hair), fleece pajamas (size 5t), Lego Duplos (girl colors), hair bows, warm/fuzzy boots for everyday wear (size 8 toddler).
Mother/Father/Guardian Name:
*
Gender
*
Female
Male
Please provide a DETAILED wish list (ranging from $35-$50 per person), including sizing for clothing and shoes. DSA will not accept gift cards as an acceptable wish list item. If you do not wish to receive gifts, please comment "no gifts".
*
This is also a great place to request FAMILY gifts - games, blankets, household items, etc.
Mother/Father/Guardian Name:
Gender
Female
Male
Please provide a DETAILED wish list (ranging from $35-$50 per person), including sizing for clothing and shoes. DSA will not accept gift cards as an acceptable wish list item. If you do not wish to receive gifts, please comment "no gifts".
This is also a great place to request FAMILY gifts - games, blankets, household items, etc.
Sibling #1 Name:
Sibling #1 Age:
Gender
Female
Male
Please provide a DETAILED wish list (ranging from $35-$50 per person), including sizing for clothing and shoes. DSA will not accept gift cards as an acceptable wish list item.
Sibling #2 Name:
Sibling #2 Age:
Gender
Female
Male
Please provide a DETAILED wish list (ranging from $35-$50 per person), including sizing for clothing and shoes. DSA will not accept gift cards as an acceptable wish list item.
Sibling #3 Name:
Sibling #3 Age:
Gender
Female
Male
Please provide a DETAILED wish list (ranging from $35-$50 per person), including sizing for clothing and shoes. DSA will not accept gift cards as an acceptable wish list item.
Sibling #4 Name:
Sibling #4 Age:
Gender
Female
Male
Please provide a DETAILED wish list (ranging from $35-$50 per person), including sizing for clothing and shoes. DSA will not accept gift cards as an acceptable wish list item.
Sibling #5 Name:
Sibling #5 Age:
Gender
Female
Male
Please provide a DETAILED wish list (ranging from $35-$50 per person), including sizing for clothing and shoes. DSA will not accept gift cards as an acceptable wish list item.