FAMILY/CAREGIVER MEMBERSHIP FORM

This form (below) is for people who a child or adult family member with Down syndrome who lives in Auckland. Membership is FREE – find out more here»

For teachers/teacher aides of a child with Down syndrome at an Auckland school, please fill out our School Membership Form»

For details on how we use the information you provide via the form below, please see our Privacy Policy.

- Step 1 of 3

DETAILS OF PERSON WITH DOWN SYNDROME

What is the name of your family member who has Down syndrome? *

First

Last

What is their gender? *

• Female
• Male

Were they diagnosed before birth? *

• Yes
• No

What is their date of birth? *

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Please enter the date of birth of the person with Down syndrome.

Were they adopted? *

• Yes
• No

Do they have any health issues (eg. heart defect, colostomy)?

What is their home address? *

Suburb *

City *

Post Code *

Do they have their own email address (optional)?

What is their ethnicity? *

You may add more than one ethnicity.

What type of Down syndrome do they have? *Trisomy 21MosaicTranslocationUnknown

Next

PARENT/CAREGIVER DETAILS

What is your name? *

First

Last

What is your gender? *

• Female
• Male

What is your relationship to person with Down syndrome (eg. mother, father, sister, caregiver etc)? *

What is your email address? *

What is your primary phone number?

Do you live at the same address as the person with Down syndrome? *

• Yes
• No

If no, please enter your home address: *

Caregiver 1 suburb *

Caregiver 1 city *

Post Code (copy) (copy) *

Would you like to add contact details for another caregiver? *

• Yes
• No

Please note: ideally we like to collect details of two caregivers, usually another parent or relative.

All of our members are added to our email list where we send out occasional updates with our latest news, events and ticket offers. You are welcome to unsubscribe from this list at any time, but they are the main way we keep in touch.

Next

Name of another parent/caregiver *

First

Last

What is their gender? *

• Female
• Male

What is their relationship to person with Down syndrome (eg. mother, father, sister, caregiver etc) *

Email address of other parent/caregiver

Main phone number of other parent/caregiver

Do they live at the same address as the person with Down syndrome? *

• Yes
• No

If no, please enter their home address: *

Suburb *

City *

Post Code *

Please add any comments you may have (optional):

After pressing submit, you will be emailed a copy of the form. Please check your junk/spam folder.

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