PARENT/LEGAL GUARDIAN MEMBERSHIP "*" indicates required fields Primary Parent/Legal GuardianFirst Name:* Last Name:* Email:* Home Address:* City:* State:* Zip:* County:* Phone:*What is your preferred language?* How do you prefer Manasota BUDS to reach out to your family?* Phone Email How did you hear about Manasota BUDS? (Select all that apply)* Hospital/clinic at screening/diagnosis (doctor, nurse, social worker, etc.)st Choice General clinic/doctor visit Education/school staff Current Manasota BUDS member Manasota BUDS Event Other Community Event Friend Media (TV, radio, social media, print media, etc.) Online Search Other What is your place of employment? Job Title Would you like to join our mailing list to receive our newsletter and event updates?* Yes No Additional Parent or Legal GuardianFirst Name: Last Name: Email Address (if different from primary): Home Address (if different from primary): City State: Zip: Phone (if different from primary):Place of Employment Job Title: Individual with Down syndromeFirst Name:* Last Name:* Birth Year of individual with Down syndromeCity where this individual was/will be born:* State where this individual was/will be born:* Timing of Diagnosis:* Prenatal Postnatal Unsure Please list any additional medical conditions your child/teen/adult has or had (Select all that apply): Alzheimer’s disease Anxiety disorder Attention deficit/hyperactivity disorders (ADD, ADHD) Autism Spectrum Disorder (ASD) Celiac Disease Depressive disorder Gastrointestinal disorder Hearing loss (corrected or uncorrected) Heart/cardiac complications Hypothyroidism Infantile Spasms (corrected or uncorrected) Leukemia Seizures Sleep apnea Vision disorder (corrected or uncorrected) No medical conditions This individual’s ethnicity is: Hispanic Not Hispanic Prefer not to say This individual’s race: Asian Black Hawaiian or Pacific Islander Native American/American Indian/Alaska Native White Prefer not to say Other This individual’s gender: Male Female Non binary Prefer not to say Household SiblingsIf your family member with Down syndrome has adult siblings that live outside your home, please encourage those siblings to become Manasota BUDS members. There is no charge for membership.Sibling 1 First Name: Sibling 1 Last Name: Sibling 1 Birth YearSibling 2 First Name: Sibling 2 Last Name: Sibling 2 Birth YearSibling 3 First Name: Sibling 3 Last Name: Sibling 3 Birth YearOther InformationAt the time your doctor first told you that your baby has or likely has Down syndrome, did you receive free information about Down syndrome from the hospital, state, or local organization/s? Yes Now I don’t remember Are you interested in potential volunteer opportunities with Manasota BUDS? Acknowledging “YES” grants us permission to contact you regarding your expressed interest. Yes No If your loved one with Down syndrome is an adult, does the individual live: Independently With Parent(s) With Sibling(s) With non-parent/non-sibling guardian With Friends In a group home In a state-funder facility (e.g. state-supported living center, state hospital, etc.) Other General Comments
