Primary Parent/ Legal Guardian *

First Name

Last Name

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Would you like to join DSACT's Comité Latino social group (Spanish-speaking group)? *

Yes

No

How do you prefer DSACT to first reach out to your family?

Phone

Email

How did you hear about DSACT?

Hospital/clinic at screening/diagnosis (doctor, nurse, social worker, etc)

General clinic/doctor visit

Education/school staff

Current DSACT member

DSACT board member

DSACT event

Other community event

Friend

Media (TV, radio, social media, print media, etc)

Online search

Other

Would you like to join our mailing list to receive our newsletter and event updates? *

Yes

No

Additional Parent or Legal Guardian

First Name

Last Name

Home Address (if different from Primary)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone (if different from Primary)

(###)

###

####

First and last name of individual with Down syndrome *

First Name

Last Name

Date of birth of individual with Down syndrome *

MM

DD

YYYY

Timing of diagnosis?

Prenatal

Postnatal

Unknown

Please list any additional medical conditions your child/teen/adult has.

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

Leukemia

Sleep apnea

Vision disorder (corrected or uncorrected)

No medical conditions

This individual's ethnicity

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

Female

Male

Non binary

Prefer not to say

At the time your doctor first told you that your baby has or likely has Down syndrome, did you receive the information about Down syndrome from the Texas Down Syndrome Information Act?

Please see first row of images below.

Yes

No

N/A, baby was not born in Texas

I don't remember

At that time, did your doctor give you any information about Down syndrome?

Please see bottom row of images below and select all that apply.

Understanding a Down syndrome Diagnosis

A Promising Future Together

No other information was provided

I can't remember/don't know

If someone other than a doctor first told you that your baby has or likely has Down syndrome, who was that person?

Nurse

Genetic counselor

Social worker

Other

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 friend(s)

in a group home

in a state-funded facility (e.g., state-supported living center, state hospital, etc)

Other