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Pathways ™ Application Form


Thank you for your interest in DSG’s Pathways ™ Program. Please complete and submit this application form. We will review your information then follow-up with an email or phone call to schedule your 15-minute consultation, which is the next step in the application process. Specific medical and diagnostic information can be discussed on the phone rather than submitted in this electronic form, for the purpose of protecting confidentiality. Please submit one form per child. If you have any questions, call #913-213-5484 or email

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

    • malefemale

    • 1 households2 households


    • 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?

    Home/Community Information:

    • yesno

    Educational Information:

    School district:

    • Occupational TherapySpeech-Language TherapyPhysical TherapyVision ServicesHearing ServicesAssistive TechnologyNone

    Additional Questions:

    • yesno

    • yesno

    • yesno

    • 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