Paid Membership

Membership
*REQUIRED
A family membership covers six (6) members per household, which includes (and requires) one family member with special needs.
Applicant Info
*REQUIRED
Name
*REQUIRED
Address, City, State, & Zip
*REQUIRED
Cell Phone
*REQUIRED
Email (Primary)
Alternate Contact Information
Home Phone
Alternate Phone
Email (Secondary)
Additional Family Members

Please complete this section to include additional household members on your 2017 DSA of NWI Membership.

PERSON 1

First & Last Name
Phone Number
Email
Year of Birth
Disability
Disability Type

PERSON 2

First & Last Name
Phone Number
Email
Year of Birth
Disability
Disability Type

PERSON 3

First & Last Name
Phone Number
Email
Year of Birth
Disability Type

PERSON 4

First & Last Name
Phone Number
Email
Year of Birth
Disability
Disability Type
Important (Optional) Information

The following information is EXTREMELY IMPORTANT for funding purposes; however, optional and will be kept confidential.  This information is gathered for the purposes of applying for grants, which often times require DSA of NWI & Chicagoland membership data to the grantor to determine and/or approve the Down Syndrome Association as a qualified applicant.

Race/Ethnicity
Family Income /year
Father
Education Level
Profession
Mother
Education Level
Profession
Waivers
*REQUIRED
Please Note:  The DSA of NWI & Chicagoland loves pictures.  We love sharing those pictures with the public (on social media, in newsletters and for marketing purposes) even more! 
*REQUIRED
Payment Information

If you have any questions please contact the DSA by phone at (219) 838-3656 or email at dsa@dsaofnwi.org.

*REQUIRED
*REQUIRED
Visa MasterCard American Express Discover
*REQUIRED
/
*REQUIRED
? Visa®, Mastercard®, and Discover® cardholders
Your security code is the 3-digit code at the end of the signature field on your card's back.

American Express® cardholders
Your security code is the 4-digit code located above the actual credit card number on your card's front.
*REQUIRED
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