HONG KONG DOWN SYNDROME ASSOCIATION

Document Sample
HONG KONG DOWN SYNDROME ASSOCIATION Powered By Docstoc
					THE HONG KONG DOWN SYNDROME ASSOCIATION                         CONFIDENTIAL    Code No.A002
Membership Application
Please fill in the following application form and send it with your membership fee
to : G/F, Wing A, Chun Tung House, Tung Tau Estate, Kowloon. Cheque should be made
payable to " The Hong Kong Down Syndrome Association ". If there is any enquiry,
Please call 2718 7778.
Eligibility:
Adults aged 18 or above and are one of the followings:
  1) Persons with Down Syndrome, or
  2) Persons who have a child/relative with Down Syndrome
Membership Fee:
  1)  General Members           $30 per year (annual renewal of membership in April)
  2)  Life Members              $200
Types of Membership:
  1) □ New Member:    A)   □ General     □ Life
  2) □ Renewal:(Membership No._______________________________)

     For Office use:
     Membership No._______________________         Receipt No. _______________________



A.    Details of Members with Down Syndrome
     Name:______________________________       Sex:_____        I.D. No. _____________________
     Interest/Hobbies: ______________________
     Nationality: __________________________ Language: _______________________________
     Date of Birth:________________________Occupation: ______________________________
     Name of School or Workplace: ____________________________________________________
     Contact Person for Emergency: ___________________________________________________
     Contact Telephone no. for Emergency:_____________________________________________(Mobile)

     Main Form of Disability
      □ Down Syndrome   □ Mentally Handicapped     □ Autism       □ Slow Learning Development
      Condition: (More than 1  allowed)
      □ Spasm                              □ Loss of Sight/Weak Sight
      □ Loss of Hearing/Weak Hearing       □ Language Barrier
      □ Physically Handicapped            □ Mental Illness
      □ Autism                            □ Reading and Writing Barrier
      □ Slow Learner                      □ Others, please specify: ____________________
      Level of Mental Disability:□Mild(IQ:50-70) □Moderate(IQ:25-49) □Severe(below 25)
        □ Still to be evaluated/Expecting results of evaluation
        □ Do not know/Do not remember
        □ Others, please specify:_______________________


 Health Condition: Any other long-term illness? □ Yes (please specify):___________
                                                      □    No
 On any long-term medication? □ Yes (please specify):_______________               □ No
   Other physical/health/mental and behavioral problem: ________________________________
   _____________________________________________________________________________________
   Any other special features: _________________________________________________________
   _____________________________________________________________________________________
   Studying/Working     Situation:    □    At   school/At      Work,   Name    of    School/Training
   Centre/Workplace: ____________________________________________________________________
   □Type of service waiting for:______________________
   □ At   home, but   not receiving   or    waiting   for   any   formal   education,    training   or
   employment service
   □Others, please specify: ____________________________________________________________
   Areas in which you think your child having learning difficulties needs to improve on:
   (Place the areas in order 1-5 in the □ , 1 being the area most needed to be improved
   on, etc., please choose no more than 5 options.)


□Strengthen language communication ability        □Learn to deal with own emotions
□Train for a good physique                        □Improve moral concepts
□Learn to look after his/herself                  □Learn to serve others
□Develop hobbies                                  □ Learn to get along and communicate with
                                                  people(including family and friends)
□Learn to use community facilities                □Others, please specify:
   I would like □ /would not like □ to be contacted by representatives of the Parents
   Committee for expression of concern of recommendation of suitable activities.
B. Details of Parents/ Carers:
   Name:______________________________          Sex:________       I.D.No. _____________________
   Date of Birth: _____________________         Occupation: __________________________________
   Nationality: _______________________         Language:____________________________________
   Relationship with members with Down Syndrome: _______E mail: _________________________
   Correspondence: _____________________________________________________________________
   Contact Telephone no.:__________________________(Home)       ______________________________(Mobile)
   E-mail No.: __________________________________________________________________________


   Family Income: □Below$5,000            □$5,001-$10,000      □$10,001-$20,000
                   □$20,001-$30,000       □Above$30,001


   Status: □Married     □Widowed   □Separated □Single □Divorced         □Others,please specify:___


   Education: □None     □University or Above
              □Primary 6 or Below           □Others, please specify:__________
              □Secondary


   Children: Number of Children:________        Age of Each Child:_________
          Number of Children with Down Syndrome: ____________
          Ranking of Child with Down Syndrome: ______________
C. Problems Encountered in the Family (please place them in the order 1-5 in the □, 1
being the most difficult, etc. , choose no more than 5 options)


 □ Health and medical problems of a child/children with Down Syndrome
 □ Educational problems of a child/children with Down Syndrome
 □ Emotional behavioral problems of a child/children with Down Syndrome
 □ Social problems of a child/children with Down Syndrome
 □ Future plans of a child/children with Down Syndrome
 □ Problems between a child/children with Down Syndrome and sibling(s)
 □ Acceptance of a child/children with Down Syndrome by people within the community
 □ Problems between a child/children with Down Syndrome and parents
 □ Discipline of a child/children with Down Syndrome
 □ Family financial problems.
 □ Communication and division of labour between family members.
 □ Spousal problems caused by difference of opinion on care and discipline of
    child/children
 □ Marital problems with spouse
 □ Others, please specify:__________________________________________________________


D. Are you willing for parents and staff of this centre to further comprehend your
   current situation and service needs through telephone or home visits?
    □ Willing      □ Unwilling


E. Are you willing for the contact person of the Parents Committee of this centre to
  get in touch for care visits or introduction of activities?
  □ Willing      □ Unwilling


  I voluntarily offer the above personal information to HK Down Syndrome Association
  for programmes application and personal contact. I fully understand I have the right
  to inquire my personal information, and I have the responsibility to update it in
  case of any changes.




  Signature:______________________________                         Date____________________________




  Form/dsamembership/04-2000revised/12-2000revised/4-2007revised