Parent Volunteer Profile

Name

First Last

Phone

Address

Address Line 1 Address Line 2 City State ZIP Code

Child's Name

First Last

Child's Date of Birth

When did you receive your child's Down syndrome diagnosis?

Prenatally

At Birth

Other

Was your child born with a heart defect?

Yes, AVSD

Yes, PDA

Yes, Tetralogy Of Fallot

Did/does your child have any other significant medical complications or diagnoses?

For example: feeding tube, stay in the NICU, hearing issues, etc.

What are some "key facts" about you or your family that would assist me in matching you with a family?

For example: military family, have 5 kids, I am a full time working mom, I am a single mom, I have twins, I have lost a baby.. etc)

What distance and/or radius are willing to drive for an in-person delivery?(Required)

Are you connected with other Down syndrome organizations (local, national, international)? Please use a comma to separate values.

Additional comments

Your t-shirt size

Your birthday

Please upload a photo of you and your child (or family).

Drop files here or

Max. file size: 256 MB.

Jack's Basket can use my photo and story in marketing materials (social media, brochures, website, etc). If no, please leave unchecked.

Yes!

Yes, but please contact me first.

Phone

This field is for validation purposes and should be left unchanged.