The PREP Program - Education and Resources for Individuals with DS and their families

Educating since 1988

Promoting Full Inclusion for Individuals with Down Syndrome

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Family Support Registration

The information parents provide below is for registry purposes only. Family support liaisons use the registry to make contact with families who have a child with Down syndrome and to help families connect with services in the community. Our goal is to assist families in developing a personalized support network that enables their child to integrate successfully in family, school and community life.

Personal Information:

My child's name is
(First/Middle/Last):

Sex: DOB (YY/MM/DD):

School He/She attends:

Address of the School:

Phone # of school:

Current Grade:

My child lives with:

Language(s) spoken in the home:

Translator required:

Mother

First/Last Name:

Mailing address:

Home #:

Work #:

Cell #:

Postal code:

Email:

Father

First/Last Name:

Mailing address:

Home #:

Work #:

Cell #:

Postal code:

Email:

Guardian/Foster Family

First/Last Name:

Mailing address:

Home #:

Work #:

Cell #:

Postal code:

Email:

My child's brothers/sisters are:

Name:	Sex:	DOB (YY/MM/DD):
Name:	Sex:	DOB (YY/MM/DD):
Name:	Sex:	DOB (YY/MM/DD):
Name:	Sex:	DOB (YY/MM/DD):

My family has the support of extended family close by:

This year my child has participated in the following community activities		This year my child is enrolled in the following programs for children with special needs:
	Art		Between Friends
	Church activities		Disabled Skiing Association
	Dance		Special Olympics
	Brownies or Guides or Scouts		Challenger baseball
	Music		Opening Gaits
	Sports		Other
	Other

My family is presently a member in good standing of:

	AACL (Alberta Association for Community Living)	You are invited to participate in the national DSRF database of individuals with Down syndrome. This information is used to identify medical, education and social trends. This is a voluntary registry for individuals interested in participating in specific projects or research pertaining to all aspects of Down syndrome.
	The PREP Program
	CDSS (Canadian Down Syndrome Society)
	DDRC (Developmental Disability Resource Center)
	DSRF (Down Syndrome Research Foundation)
	Other

My child/family is presently registered with:

	Ability society
	Children's Link
	FSCD (Family Support for Children with Disabilities)
	Gateways
	Down Syndrome Clinic at ACH
	Early Intervention Programs (0-3yrs) Please name:
	Respite Agency
	Other

How can we help?

I would appreciate receiving information about services for:
My Child:		My family:
	Education		Parent workshops
	In home support		Crisis support
	Health		Provincial/Federal Assistance
	Recreational		Family workshops (i.e.: sib-shops)
	Social		Family therapy/Marriage counselling
	Therapy		Respite services
	Other		Other

At this time a Family Support Liaison can help me with the following:

I am interested in joining a parent support group to discuss concerns that are of common interest to families who have a child with Down syndrome (e.g. advocacy, acceptance, future planning, specific medical conditions)

I suggest the following topic(s):

Name: