2020 Membership Form

Individual with Disability
Name*
First Last
Disability Type*
Birthdate*
MM slash DD slash YYYY
Gender
Race/Ethnicity*
- White
- Black or African American
- Latino or Hispanic
- Asian or Pacific Islander
- American Indian or Alaska Native
- Other
For grant purpose only.
School/Grade (if applicable)
Phone*
Email*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Primary Contact 1
Relationship to person with disability
Name
First Last
Phone
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Contact 2
Relationship to person with disability
Name
First Last
Phone
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Photo Release
I agree to the photo release policy
I grant the Down Syndrome Association of Brazos Valley (DSABV), its representatives and employees the right to take photographs of me and my family as part of my membership. I authorize DSABV, its assignees and transferees to use and publish the same in print and/or electronically. I agree that DSABV may use such photographs of me and my family with or without my name for any lawful purpose, including such purposes as publicity, illustration, advertising, and web content. I have read and understood the above.
Additional Family Members
Family member 1
First Last Relationship Birthday
Family member 2
First Last Relationship Birthday
Family member 3
First Last Relationship Birthday
Family member 4
First Last Relationship Birthday
Family member 5
First Last Relationship Birthday
Additional Information
How did you hear about DSABV?*
What type of information or workshops would you like to receive from DSABV?
Are you fluent in any of the following languages?*
- Chinese
- French
- Japanese
- Spanish
- Other
- N/A
Please select all that apply

Individual with Disability

Primary Contact 1

Primary Contact 2

Additional Family Members

Additional Information