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)
Person with Down Syndrome/Special Needs
*REQUIRED
First & Last Name
*REQUIRED
Birthday
*REQUIRED
*REQUIRED
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

PERSON 2

First & Last Name
Phone Number
Email
Year of Birth

PERSON 3

First & Last Name
Phone Number
Email
Year of Birth

PERSON 4

First & Last Name
Phone Number
Email
Year of Birth
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