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New membership enrollment form 4.6.13 - final for website
- 1. PDSSN Membership Enrollment Form To pay by check, please mail completed form and dues to: Deborah Woolard, 4049 Max Drive, Winston-Salem, NC 27106 Family Information: First Name Last Name Street City State Your Email Address County Zip Best Contact Phone Number Additional Phone Number Your Employer Your Title Spouse First Name Spouse Last Name Spouse Email Address Spouse Cell Phone Spouse Employer Spouse Title Please indicate your connection with our community: Parent of a Child with Ds Other relative of an individual with Ds Individual with Ds Friend of individual with Ds Sibling of an individual with Ds Professional Grandparent of an individual with Ds Other If you have a child with Down syndrome, please share the following info so we can provide activities that will meet the needs and interests of your family: Name of child with Ds Birthday (mm/dd/yyyy) Name of Additional Child Birthday (mm/dd/yyyy) Name of Additional Child Birthday (mm/dd/yyyy) Name of Additional Child Birthday (mm/dd/yyyy)
- 2. How did you become aware of our organization? Please select ALL that apply. Referred by a physician Facebook Referred by family, friend or colleague Twitter Searching the internet / PDSSN website Linked In Attended an event News article, radio, TV Other - Please write in the box to right ==> Interests: How important is it to you to have child care available at events: I must have child care provided at PDSSN events in order to attend. I sometimes need child care provided at PDSSN events in order to attend. I never need child care provided at PDSSN events. Place a check next to ALL the days of the week when you can usually attend a family gathering, such as educational programs, social events, etc: Monday Evenings Saturday Afternoons Tuesday Evenings Saturday Evenings Wednesday Evenings Sunday Afternoons Thursday Evenings Sunday Evenings Friday Evenings Place a check next to ALL the days of the week when you can usually attend a family dinner night out event with other PDSSN families: Monday Evenings Friday Evenings Tuesday Evenings Saturday Evenings Wednesday Evenings Sunday Evenings Thursday Evenings Please indicate how you would like to contribute to PDSSN. Select ALL that apply: Occasional Attendee at Events Occasional Volunteer Frequent Attendee at Events Active Volunteer PDSSN Board Member Committee Chairperson Please indicate if you¡¯d like to be contacted about volunteer opportunities with PDSSN: Yes No Please let us know how we can best meet your needs and interests by indicating ALL the programs you'd be interested in attending: Buddy Walk Ladies Night Out Family Social Gatherings D.A.D.S. (Dads Appreciating Ds) New Parent Ds Information Meeting Transition Tips Playgroup for Children with Ds Next Chapter Book Club Social Events for Teens with Ds Sensory Integration Presentation Social Events for Adults with Ds Ear Nose Throat Physician Presentation Elementary School Options and Info Ophthalmology Physician Presentation Middle School Options and Information Sexuality Program High School Options and Information Special Needs Trusts Post Secondary Program Information Guardianship IEP Planning Financial & Estate Planning KIDS FEST SSI Eligibility and Benefits Other - Please write in the box to right ==>