NCKDSS Questionnaire

NCKDSS Questionnaire

Welcome to NCKDSS. This form will be forwarded to the NCKDSS Board of Directors. Should you have any inquiries, please reach out to Shella Thoman at nckdssbuddywalk@yahoo.com or dial 785-275-1777.
Would you like to be an official member of the NCKDSS?*

YesNo
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Mom's Name

First NameLast Name
Mom's Date of Birth

MonthDayYear
Dad's Name

First NameLast Name
Dad's Date of Birth

MonthDayYear
Stepparent's Name

First NameLast Name
Stepparent's Date of Birth

MonthDayYear
Caregiver's Name

First NameLast Name
Caregiver's Date of Birth

MonthDayYear
Sibling's Name

First NameLast Name
Sibling's Date of Birth

MonthDayYear
Sibling's Name

First NameLast Name
Sibling's Date of Birth

MonthDayYear
Sibling's Name

First NameLast Name
Sibling's Date of Birth

MonthDayYear
Sibling's Name

First NameLast Name
Sibling's Date of Birth

MonthDayYear
Please add any additional siblings in the comments section below.
Email (Use all lowercase letters)*
example@example.com
Alternate Email, if applicable. (Use all lowercase letters)
example@example.com
Phone Number*
Please enter a valid phone number.
Alternate Phone Number, if applicable.
Please enter a valid phone number.
Primary Address*

Street Address

Street Address Line 2

CityState

Zip Code
Secondary Address (optional)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What county do you live in? ex. Cloud*
Age of Mom at Conception*
Age of Dad at Conception*
Birth Order of Child*

FirstMiddleYoungest
Type of Down Syndrome

Trisomy 21MosaicTranslocationUnknown
Separation of 1st and 2nd toe*

YesNoPrefer Not to Answer
Heart Defect (including holes)*

YesNoPrefer Not to Answer
Heart Surgery*

YesNoPrefer Not to Answer
Palmar Crease*

YesNoPrefer Not to Answer
Sleep Apnea*

YesNoPrefer Not to Answer
Thyroid Problems*

YesNoPrefer Not to Answer
Tubes*

YesNoPrefer Not to Answer
Glasses*

YesNoPrefer Not to Answer
Sleep Study*

YesNoPrefer Not to Answer
Gastrointestinal Problems*

YesNoPrefer Not to Answer
Hearing Aids*

YesNoPrefer Not to Answer
Special Olympics*

YesNoPrefer Not to Answer
Strabismus*

YesNoPrefer Not to Answer
Cancer*

YesNoPrefer Not to Answer
Prenatal Diagnosis*

YesNoPrefer Not to Answer
Will you attend the Buddy Walk?

YesNoMaybe
Please enter any comments, notes, or additional siblings. Thank you.
I understand by completing and returning the NCKDSS Questionnaire, our Family is considered an official member of the NCKDSS for the calendar year of 2024. As a member of the NCKDSS, we intend to support and carry out the mission of the NCKDSS. I, the parent/caregiver of said Star, authorize the NCKDSS the use of photos associated with our family to assist promoting awareness and acceptance. Upon request, review, and approval by the NCKDSS Board of Directors, our membership makes us eligible for NCKDSS Grants.
Yes. I understand.
Date

YearMonthDay
Date
Hour MinutesAM/PM Option
Should be Empty: