Name of Individual with Down Syndrome *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Parent / Guardian Name(s): *

First Name

Last Name

Home Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Other Phone

(###)

###

####

Siblings (at home):

First Name

Last Name

Type of Membership *

New

Renewal

A membership directory is published and mailed to members biannually. Do you wish to be included in the directory? *

YES, include my name

NO, do not include my name

Internet and Newsletter Publishing Consent *

I consent that my child's picture or mine may be published on a web page or in a newsletter produced by the Alaska Chapter National Down Syndrome Congress. Any caption will contain only the first name of those in the picture. No home address or phone number will appear with the picture.

I grant permission for use

I deny permission for use

Would you like to receive texts from Alaska Down Syndrome Network? *

Yes

No

ANNUAL MEMBERSHIP is $25; the fee can be waived if it is a hardship. Make checks payable to AK Chapter NDSC. Receipts sent on request. *

$25 enclosed / will pay online

Check

Cash

Please waive fee