Membership Form Down Syndrome Association – Hudson Valleywww.dsavh.org Name Primary Phone School District Secondaryl Phone Address Email Family Member with Different Ability Date of Birth Do you receive services from OPWDD? Yes No Do you have a TAB Number? Yes No Name and Ages of Siblings Annual Survey for Family Suppor Services (FSS)Please rate on a scale from 1 to 5, using 5 as the best DSAHV has been helpful and informative to me, as a parent 1 2 3 4 5 DSAHV's newsletter, emails, Facebook page and website are informative 1 2 3 4 5 DSAHV provides opportunities for social networking with other families 1 2 3 4 5 I feel having contact with other parents is important 1 2 3 4 5 DSAHV offers useful information by hosting informative workshops 1 2 3 4 5 Do you use DSAHV as your education advocate/coach Yes No I prefer to Go "GREEN" and receive all correspondence by email No thank you, please use the postal service At events, DSAHV may take pictures to add to our website, Facebook page, brochures or flyers Yes, I give permission to use my family member’s photos No thank you, we are camera shy I would like to volunteer and I’d like more information on how I can lend my talents Occasionally, DSAHV will hold seminars where we bring in guest speakers to teach us about various topics of interest. From the following list, please prioritize THREE topics you are most interested in Behavioral Support Issues for Older Adults Sibling Support Employment Inclusive Education Speech Therapy Special Education Law and IEP’s After High School Trusts, SSI, Medicaid Group Homes and Residential Issues Other If Other, please specify What can DSAHV do to help improve our services for you and your family Membership for the year is $12. Please make checks payable to DSAHV and they can be mailed to: DSAHV, PO Box 161, Hopewell Junction, NY 12533 Send