Document Sample
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.
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:__________

   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
 □ 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____________________________