One moment please...
Information Update
Name
*
First Name
Last Name
Spouse or Partner
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
*
Parent of a child with Down syndrome
Expecting a child with Down syndrome
Family Member of individual with Down syndrome
Individual with Down syndrome
*
First Name
Last Name
Due Date
(mm/dd/yyyy)
Birthday of Individual with Down Syndrome
*
(mm/dd/yyyy)
Your Relationship to Individual with Down Syndrome
*
select one
Mother
Father
Grandparent
Guardian
Sibling
Extended Family
Siblings
Employer
School District
Household Income
*
This information is collected 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
Ethnicity of Individual with Down Syndrome
*
This information is used for grant purposes. Please check all that apply.
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Prefer Not To Answer
How did you find DSA?
select one
Internet Search
Referred by Health Care Provider
Referred By Friend
Social Media
Other
Questions and Comments