Ordinary (for individuals with Down
Syndrome and their families)
Affiliate (for agencies, organisations,
service providers etc.)
I enclose payment for the amount of:
$30.00 individual membership
$50.00 2 year individual memebership
$50.00 Affiliate memebership
I request that the NZDSA waive this
fee due to financial constraints. I understand this is at
the discretion of the Executive Committee and confidentiallity
will otherwise be respected.
Parents / Association Name(s):
Address:
Phone No:
Fax No:
Email Address / Website:
Occupation:
Family / Whanau Only
It would be helpful to the NZDSA if you are willing to share
with us the following information about your family. You are
under no obligation to provide this information. The NZ Down
Syndrome Association complies with the Privacy Act 1993 and
the Health Information Privacy Code 1994.
Name(s) of children with Down Syndrome:
Date of Birth(s):
Ethnicity:
Type of Down
Syndrome:
Trisomy 21
Mosiac
Translocation
Unknown
Diagnosis before
birth: Yes
No
Any additional medical conditions / health issues eg,
heart defect, autism, colostomy (Please list here):
Your child's birth order ( eg eldest of 2):
Other information we may find helpful, eg. Skills you
have that could benefit the NZDSA
Do you have any suggestions about how the NZDSA could
improve service to people whose lives have been changed
by Down syndrome?
The NZDSA thanks you for
taking the time to complete these details.
post to:
The Secretary
NZ Down Syndrome Association
PO Box 4142
Auckland
New Zealand
