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DSES January
Name / Nombre
*
First Name
Last Name
Email / correo electronico
*
Verify Email
*
Address / Dirección
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Phone / Telefono
*
I am a / Yo soy
*
Parent of a child with Down syndrome / Padre de un niño(a) con sindrome de down
Expecting a child with Down syndrome / Esperando un bebé con sindrome de down
Family Member of individual with Down syndrome / Persona con sindrome de down ó miembro de la familia
Community member / miembro de la comunidad
Profession or interest in presentation / Profesión o interés en la presentación
*
Individual with Down syndrome / nombre de la persona con síndrome de Down
*
First Name
Last Name
Birthday (or due date) of Individual with Down Syndrome / Fecha de nacimiento de la persona con síndrome de Down o del bebé que va tener
*
(mm/dd/yyyy)
Household Income / Ingreso familiar
*
This information is helpful to DSA as it is a question on some grant applications.
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 (y mayor)
Prefer not to answer / prefiero no responder
Ethnicity of Individual with Down syndrome / Etnia del niño(a) con sindrome de down
*
This information is used for grant purposes. Please check all that apply.
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