BECOME A MEMBER + RENEW MEMBERSHIP

We would love for you to be a continuing part of our activities by completing the online membership application below.  Your membership dues help us support our website, reach new parents in the community, create printed materials, offset postage costs, and sponsor organization events. Membership is open to everyone!  You do not have to be related to or have any family members who have Down syndrome to become a member of DSAA. 

DSAA's membership dues are $25.00 per year per household.

Member Information:

Name

Prefix Mr. Mrs. Ms. Dr. Prefix

First Name *

Last Name *

Suffix

Spouse's Name

Prefix Mr. Mrs. Ms. Dr. Prefix

First Name *

Last Name *

(If no spouse, please enter "n/a" for first name and last name.)

Mailing Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

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Parish

Cell Phone

Home Phone

Cell Phone - Spouse

Email Address

Email Address - Spouse

Your connection to individual with Down syndrome:

1. Parent
2. Grandparent
3. Self
4. Friend
5. Therapist
6. Medical Provider
7. Educator
8. Other

If "Other", please enter connection below.

Other connection

Name of individual with Down syndrome

Prefix Master Miss Mr. Mrs. Ms. Prefix

First Name *

Last Name *

Suffix

Date of Birth

Gender:

1. Male
2. Female

School Attending or Place of Employment

Individual with Down syndrome lives with:

1. Parent
2. Relative
3. Group home
4. Other

If "Other" please list below.

Other residence

Names of Siblings

New Membership or Annual Renewal

1. $25

Donation Amount

I would like to support DSAA with an additional tax-deductible donation of:

1. $10
2. $25
3. $50
4. $100
5. Other

If "Other", please fill in amount below.

Other Donation Amount

Comments

Credit Card Information

Cardholder Name

Credit Card #

Expiration Date

Security Code

Make this a monthly payment?

1. Yes, charge me today and on the 21st of every following month.

Make this a monthly payment?

Cover the fee associated with this online transaction?

1. Yes, I will pay an additional {transaction_fee} to cover the cost of this transaction.

Cover the fee associated with this online transaction?

Your total payment will be

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged

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To pay by check, please make checks payable to DSAA or Down Syndrome Association of Acadiana and send payment and Membership Form to:

Down Syndrome Association of Acadiana
P.O. Box 81323
Lafayette, LA 70598

Membership Form