Lower Mainland Down Syndrome Society
Information: (604) 591-2722 Fax: (604) 591-2730
Email: lmdss@telus.net Website: www.lmdss.com
Date Received:
For Office Use:
/
/
.
Day / Month / Year
New Member Registration Form
Basic Information
Name: (Mr./Mrs./Ms.) __________________________________________________________
Address: _____________________________________________________________________
City: _______________________________ Postal Code: ______________________________
Phone: (
Fax: (
) _______________ Work (
) ________________ Cell (
) _______________
) _________________Email Address Required: ______________________________
Please check one of the following:
Individual/Family Membership:
Self-Advocate Membership:
Affiliates/Corporate Members
Group

$30.00
No Charge
$30.00
$ 30.00




Cheque

Payment Method:
Credit Card
Credit Card:
Visa
______________________________
Mastercard
______________________________
Expiry Date ______________________________
Signature
______________________________
Make payable to LMDSS.
Cheque:
Cash

Mail forms and payment to # 201-13281-72nd Ave, Surrey, BC V3W 2N5
We usually send newsletters and event/news notices by mail. To “go green,” reduce printing and mailing costs,
and send information to you more quickly, we’d like to use email as much as possible.
Would you like to receive notices by email?
Would you like to receive newsletters by email?
# 201-13281-72nd Ave, Surrey, BC V3W 2N5
Yes
Yes


No
No


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Down Syndrome Connection
Please tell us about your connection with Down syndrome. By giving us the following information you
can help us set goals for the society, develop services, and connect you with members who share your
concerns. Providing the following information is voluntary. All information is kept confidential.
1. Are you a Self-Advocate with Down syndrome?
Yes

No

2. Do you have a child (children) with Down syndrome?
Yes

No

Name
_________________________
_________________________
Sex
_____
_____
Birth date
_________________
_________________
If not, please tell us why you are interested in Down syndrome. (e.g., grandparent, teacher,
teaching assistant, friend, doctor, nurse, etc.)
________________________________________________________________
Do you have other children?
Yes
Name
_________________________
_________________________
_________________________
Sex
_____
_____
_____

No

Birth date
_________________
_________________
_________________
3. Are you concerned about any medical issues? (e.g., hearing loss, vision, speech, etc.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________________________
4. Are you concerned about other issues relating to Down syndrome? (e.g., preschool, transition
between schools, life planning, employment opportunities, etc.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
5. Would you like to volunteer or help the Society in any way? Could you help in one of the
following categories? Please check those that interest you.
Board of Directors
Social Events
Fundraising
Clerical Work
Youth Group





Newsletter
Educational Advocacy
Workshop Coordination
Special Projects
Interpreter
# 201-13281-72nd Ave, Surrey, BC V3W 2N5
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


Advertising

Marketing

IT

Website

Other_____________________
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6. Do you have any special skills that you can share with us, or are you in an occupation that could
help the Society?
_____________________________________________________________________________
7. If your membership is corporate or for an affiliated group/organization, please provide the
following:
Name of contact person: ___________________________________________________
Number of members your group/organization represents: _________________________
Brief description of your group/organization:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
8. Are you a member of the Canadian Down Syndrome Society?
Yes 
No

9. Would you like to receive information about Down syndrome from other sources?
Yes 
No

10. Would you allow us to share your contact information with others interested in contacting you
regarding Down syndrome issues? We will release only the contact information you authorize.
Yes 
No

Email 
Telephone

Address

Membership Benefits












Email hotline delivering
o upcoming LMDSS event reminders, current information about Down syndrome
o local and national developments relating to people with special needs
Access to the LMDSS resource library
LMDSS newsletter DownLink, which highlights LMDSS activities, workshops, special events,
resources, parent support groups, member’s stories, up-to-date news, medical and educational
information, news from other available resources
Annual events: Summer Picnic/Christmas Party/Spring Family Dance/Buddy Walk
New-parent packages
Youth-group activities, subsidized camp opportunities
Parent support groups, subsidized workshops
IEP consultations
Post-secondary education scholarships
Research input for training upcoming professionals
Annual General Meeting voting privileges (in person or by proxy)
Ability to stand for election to the Board of Directors
# 201-13281-72nd Ave, Surrey, BC V3W 2N5
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