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Project Lifesaver Inquiry/Proyecto Salvavidas Consulta
Please fill out the form and a DSA staff member will contact you! Thanks!
Parent / Caregiver Name/ Nombre de la madre o padre / custodio
*
First Name
Last Name
Email/ correo electrónico
*
Verify Email
*
Phone/telefono
Address/ Dirección
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Phone/telefono
*
I am a
*
Parent of a child with Down syndrome /Madre o padre de una niño(a) con síndrome de down
Caretaker of an individual with Down syndrome/ Cuidador de una persona con síndrome de Down
Individual with Down syndrome/ Persona con síndrome de Down
*
First Name
Last Name
Birthday of Individual with Down Syndrome/ Fecha de nacimiento de la persona con síndrome de Down
*
(mm/dd/yyyy)
Ethnicity of Individual with Down syndrome
*
This information is used for grant purposes. Please check all that apply./ Esta información se utiliza con fines de becas. Por favor marque todos los que apliquen.
American Indian or Alaska Native/ Indio americano o nativo de Alaska
Asian/ Asiático
Black or African American/ Negro Afroamericano
Hispanic or Latino/ Hispano o Latino
Native Hawaiian or Other Pacific Islander/ Nativo hawaiano u otro isleño del Pacífico
White/ Blanco
Prefer Not To Answer/ Prefiero no responder
Household Income/ Ingreso Familiar
*
This information is collected for grant writing purposes. /Esta información se recopila con fines de redacción de becas.
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 did you hear about Project Lifesaver?/¿Cómo se enteró del Proyecto Salvavidas?
select one
DSA Communication
Internet Search
Referred by Health Care Provider
Referred By Friend
Social Media
Referred by Omaha Police Department
Other
Questions and Comments/ Preguntas y comentarios