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DSA Pool Party 2022
Total Number of Family Members Attending
*
Name
*
First Name
Last Name
Email
*
Phone
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Individual with Down syndrome
*
First Name
Last Name
Birthday of Individual with Down Syndrome
*
(mm/dd/yyyy)
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 helpful for grant applications. 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