Contact Us | Down Syndrome Innovations

Page 1

To get started, please select the option that applies to you.

What best describes the age of your loved one?

Identify Developmental or Intellectual Disability

Down SyndromeAutismADHDOther Please select all that apply

Other

Do you have multiple family members with a developmental or intellectual disability?

YesNoIf yes, a representative from Down Syndrome Innovations will be in contact with you to get more information.

Please list the names of those family members.

Baby's First Name

If not decided type "Baby"

Baby's Middle Name

Baby's Last Name

Baby's Nickname

Expectant Due Date

Gender

MaleFemaleUnknown

Child's First Name

Child's Middle Name

Child's Last Name

Child's Nickname

Date of Birth

Gender

MaleFemale

Teen's First Name

Teen's Middle Name

Teens's Last Name

Teen's Nickname

Date of Birth

Gender

MaleFemale

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

MaleFemale

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

Postal Code

County

Race:

America-Indian or Alaskan NativeAsianBi-RacialBlack or African AmericanNative Hawaiian or Pacific IslanderWhiteDiversity 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.

Ethnicity:

Hispanic or LatinoNot Hispanic or LatinoDiversity 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.

Select Educational Setting

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

Postal Code

County

Home Phone

Cell Phone

Primary Email

Employer

Page 3

Siblings

First Name

Last Name

Date of Birth

Office Address

Phone Number

Office Hours

MEDIA INQUIRIES: please contact Vanessa Figg, Vice President of Marketing, via email or direct line: 913-229-3972.

Get Connected!

Get Connected Form for Down Syndrome Innovations

Page 1

Page 2

Parents/Caregivers

Page 3

Siblings

Call Us Now

Send an Email