Get Connected Form for Down Syndrome Innovations
Page 1
To get started, please select the option that applies to you
.
Please select...
I am a parent / caregiver
I am an extended family member (ex. grandparent, aunt, uncle, cousin, etc.)
I am an educator
I am a service provider (Ex. physician, therapist, case-manager, social worker, counselor, job coach, personal care attendant, etc.)
I am an employer
Other
What best describes the age of your loved one?
Please select...
I am a expectant parent
I am a new parent (child is 0 to 1 year old 11 months)
I am a parent/caregiver of a child 2 to 5 years 11 months
I am a parent/caregiver of a child 6 to 11 years 11 months
I am a parent/caregiver of a child 12 to 17 years 11 months
I am a parent/caregiver of a adult 18 to 40 years 11 months
I am a parent/caregiver of a adult 40 + years old
Identify Developmental or Intellectual Disability
Down Syndrome
Autism
ADHD
Other
Please select all that apply
Other
Do you have multiple family members with a developmental or intellectual disability?
Yes
No
If yes, a representative from Down Syndrome Innovations will be in contact with you to get more information.
x
Please list the names of those family members.
Your First Name
Your Last Name
Your role/relationship/title
Cell Phone
Email
County
Name of my family member is ( please type first and last name)
Type of Education Setting
(select all that apply)
Public School
Private School
Charter School
Other
Age-level
(select all that apply)
Early Childhood
Elementary School
Middle School
High School
Post-Secondary
School
School District
County
Work Phone
Work Email
Personal Email
Type of setting
In-Home or Residential
Medical/Clinical
Educational
Therapeutic
Community Setting (not-for-profit, small business, assisted living, etc.)
Employer
County/Counties served
Work Phone
Cell Phone
Work Email
Personal Email
I/we employ people with a developmental or intellectual disability
I/we would like to learn more about employing people with a developmental or intellectual disability
I/we are interested in volunteering to support people with a developmental or intellectual disability
I /we are interested in sponsoring or participating in a fundraising event to support people with a developmental or intellectual disability
Business/Organization
County/Counties served
Main business Phone
Personal business Phone
Work Email
Personal Email
Share with us anything else you would like us to know about you, or how we can collaborate with you or support you. A member of our team will respond.
Affiliated Business/Organization
Cell Phone
Email
If you have any other specific questions or needs, feel free to leave us a message and a member of our team will respond.
Baby's First Name
If not decided type "Baby"
Baby's Middle Name
Baby's Last Name
Baby's Nickname
Expectant Due Date
Gender
Male
Female
Unknown
Child's First Name
Child's Middle Name
Child's Last Name
Child's Nickname
Date of Birth
Gender
Male
Female
Teen's First Name
Teen's Middle Name
Teens's Last Name
Teen's Nickname
Date of Birth
Gender
Male
Female
Does this person have their own cell phone?
Teen's Phone
Does this person have their own email address?
Teen's Email
Adult's First Name
Adult's
Middle Name
Adult's
Last Name
Adult's
Nickname
Date of Birth
Gender
Male
Female
Does this person have their own cell phone?
Adult's
Phone
Does this person have their own email address?
Adult's
Email
Street Address
Apartment or Unit
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Postal Code
County
Race:
America-Indian or Alaskan Native
Asian
Bi-Racial
Black or African American
Native Hawaiian or Pacific Islander
White
Diversity and inclusion is one of our core principles and we want to ensure we are delivering on our mission to everyone, regardless of race or ethnicity. Grant funding organizations hold DSI accountable by requesting this demographic data to ensure services are provided to an in era singly diverse community. Your answer to this question should be based on how you identify. Each person can decide how to answer. You are free to choose which bones to mark or not to mark.
x
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Diversity and inclusion is one of our core principles and we want to ensure we are delivering on our mission to everyone, regardless of race or ethnicity. Grant funding organizations hold DSI accountable by requesting this demographic data to ensure services are provided to an in era singly diverse community. Your answer to this question should be based on how you identify. Each person can decide how to answer. You are free to choose which bones to mark or not to mark.
x
Select Educational Setting
Please select...
Public
Private
Home
Post-Secondary
Out of school
School District
Page 2
Parents/Caregivers
First Name
Last Name
Your role/relationship
Address Same as Family Member on the Previous Section
Street Address
Apartment or Unit
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Postal Code
County
Home Phone
Cell Phone
Primary Email
Employer
Page 3
Siblings
First Name
Last Name
Date of Birth
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