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NEW CONSTITUENT FORM
NUEVA FORMA CONSTITUYENTE EN ESPAGÑOL HAGA CLIC AQUÍ
Contact Information
NAME/ NOMBRE
*
First Name
Last Name
EMAIL
*
Verify Email
*
PHONE NUMBER
*
SPOUSE/PARTNER'S NAME
First Name
Last Name
SPOUSE/PARTNER'S EMAIL
Verify Email
SPOUSE/PARTNER'S PHONE NUMBER
ADDRESS- ( WRITE N/A IF NO ADDRESS AVAILABLE BUT THIS WOULD BE HELPFUL INFORMATION TO PLAN PLAY DATES IN AREAS WHERE OUR FAMILIES LIVE, AS WELL AS TO DROP OFF WELCOME/HOSPITAL BAGS IF NEEDED)
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Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
TITLE
*
Select all that apply
Disabled Community Member
Parent/Guardian of someone with a disability
Family Member
Caregiver
Teacher
Administrator
Therapist
Medical Professional
Community Member
Other
Loved One Information
Are you disabled? Write Self. Have a child or adult with a diagnosis you care for? Enter their diagnosis here. If not, write N/A
NAME OF LOVED ONE WITH DIAGNOSIS
*
First Name
Last Name
DIAGNOSIS OF YOUR LOVED ONE
*
BIRTHDATE OF LOVED ONE WITH DIAGNOSIS
*
(mm/dd/yyyy)
SCHOOL LOVED ONE IS ATTENDING
2nd Loved One Information
Have another child or adult with a diagnosis you care for? Enter their diagnosis here. If not, leave this section blank.
NAME OF SECOND LOVED ONE WITH DIAGNOSIS
First Name
Last Name
DIAGNOSIS OF YOUR SECOND LOVED ONE
BIRTHDATE OF SECOND LOVED ONE WITH DIAGNOSIS
(mm/dd/yyyy)
SCHOOL SECOND LOVED ONE IS ATTENDING
ANYTHING ELSE YOU'D LIKE US TO KNOW?
WOULD YOU LIKE TO HELP US CONTINUE TO CREATE COMMUNITY? CONSIDER DONATING TODAY!
$100
$50
$25
$
DONATION SCHEDULE
One Time
Monthly
Quarterly
Yearly
HOW DID YOU HEAR ABOUT US?
*
select one
WORD OF MOUTH
SOCIAL MEDIA
PODCAST
NEWSPAPER ARTICLE
OTHER
WHICH MEETUPS WOULD YOUR FAMILY BE INTERESTED IN ATTENDING?
Family Meetups - meet up at different parks/places in Sonoma County
Moms' Meetups - just for moms to take a break and connect
Dads' Meetups - just for dads to take a break and connect
Siblings Support Group for siblings aged 2-6
Sibling Support Group for siblings aged 7+
New Family Support Group for families with children 0-3 years old - This group is run by a volunteer MFT who has a child with a rare diagnosis
ARE YOU INTERESTED IN VOLUNTEERING?
Please also fill out a volunteer form
Help with meetups at different parks/places in Sonoma County
Annual Gala
Volunteer at Special Events
Would you like to receive emails and the Monthly Newsletters from CGS?
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Yes, I would like to receive emails and the newsletters from Common Ground Society™
No
