Membership Form

Provide the information requested below and a representative from Up With Downs will be in touch wth you shortly. Thank you!

* Denotes a required field.

Title :

Mr.

Mrs.

Ms.

Dr.

First Name * :

Middle Initial :

Last Name * :

Address * :

City * :

State * :

Zip * :

Home Phone * :

Cell Phone :

Email Address * :

Spouse Title :

Mr.

Mrs.

Dr.

Spouse First Name :

Spouse Middle Initial :

Spouse Last Name :

Relationship to child with Down syndrome :

Parent

Grandparent

Sibling

Other

If Other, please specify relationship :

Name of Child with Down syndrome :

Male

Female

Birth Date :

Please list names and ages of siblings below :

Volunteer Opportunities :

I would like to volunteer for the 2008 Buddy Walk
I would like to volunteer for the 2008 Christmas Party
We would be interested in attending Weekend speaker events

Membership Opportunities :

Yes! We would like to become members of Up With Downs for $20.00
Yes! We would like to renew our Up With Downs membership for $20.00