The Down Syndrome Association of
Central Florida Membership Form

Please enter the following information.
Items marked red are required fields.

Contact Information
Title:
First Name:
Middle Name:
Last Name:
Enter address, city, state and postal code
as filed with your financial institution.
Address:
City:
State:
Postal Code:
County:
Email:
Phone:
Fax:

Select relationship to person(s) with Down syndrome
Parent
Relative
Educator
Friend
Person with Down syndrome
Health Care
Other

Optional information below provides data for funding
Marital Status: Single Married Divorced Widowed
Gender: Male Female
Primary Language:
Ethnicity: Caucasion African American Hispanic Other
Education: High School Bachelors Masters PHD MD

Person with Down Syndrome
Name:
Health Problems:
Lives with: Parent Relative Group Home Independent Other
Special Needs Trust established: Yes No Need Information

Support Options
Amount: $20
$50
$100
$250
$500
$1000
Other Amount $
Support Frequency:

I would consider a bequest to the DSACF in my estate planning.
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Payment Information
Card Type:
Card Number:
CVV2: Click here for CVV2 information.
Expiration Date: mm/yyyy

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