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Pathways ™ Participant (child or young adult with Down syndrome)

• First Name*
  
• Last Name*
  
• Gender*
  malefemale

• Ethnicity (optional)
  
• Date of birth*
  
• Household
  1 households2 households

Parent/caregiver's

• First Name*
  
• Last Name*
  
• Relationship*
  
• First Name
  
• Last Name
  
• Relationship
  
• Primary address*
  
• • City*
  • State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
  • Zip*
• Primary phone*
  Please select...cellhomework
• Secondary phone
  Please select...cellhomework
• Primary email address*
  
• County you reside in?*
  
• Do you currently have a case-manager through your county’s CDDO (Community Developmental Disability Organization)?*
  yesnoI’m not sure

Please list any other family members or trusted adults you would like to involve in the Pathways™ sessions with your child?

• First name
  
• Last name
  
• Relationship
  
• First name
  
• Last name
  
• Relationship
  
• First name
  
• Last name
  
• Relationship
  

Home/Community Information:

• Please list any organized activities your child participates in within your community.
  
• Is your child currently receiving therapy services in the home or at another agency in the community?*
  yesno
• Please describe.
  
• Please list any DSG programs or events your child has attended in the last year?
  

Educational Information:

• Child’s current grade level:*
  Please select...Pre-KKindergarten1st2nd3rd4th5th6th7th8th9th10th11th12th18-21 transitional program (high school)College program (i.e. THRIVE, Propel)
• Which setting is your child’s education provided in currently:*
  Please select...public schoolprivate schoolhome school

School district:

• Does your child have an IEP?*
  Please select...yesno
• Does your child have a 504 plan?
  Please select...yesno
• Please check the therapy services your child is currently receiving in school?*
  Occupational TherapySpeech-Language TherapyPhysical TherapyVision ServicesHearing ServicesAssistive TechnologyNone

Additional Questions:

• Are there any concerns about your family accessing transportation to DSG for Pathways ™ services?*
  yesno
• Do you have regular access to the internet so your family can access information on the Pathways ™ portal at home?*
  yesno
• Would you like to talk to the Director of Family Services about needs-based financial assistance for Pathways ™?
  yesno
• What is your preferred month to begin your Pathways ™ year?*
  Please select...January, 2020February, 2020March, 2020April, 2020May, 2020June, 2020July, 2020August, 2020September, 2020October, 2020November, 2020December, 2020
• How did you hear about Pathways ™?
  Mailed brochureDSG’s social mediaDSG’s Connections newsletterDSG ConferenceDSG staff memberCDDOPhysician or Medical clinicSchool district personnelAnother DSG familyOther
  
• I have read & accept the* TERMS & CONDITIONS

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