DSA Adopt-A-Family Program

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We are happy to support you and your family this holiday season. Please note while we would love to assist all families in need, DSA cannot guarantee all registered families will be matched.

Please review the guidelines below before applying.

Eligibility: We are currently only able to serve families who are registered members of Down Syndrome Alliance of the Midlands living in the Omaha metro area.

Expectations: All children in a family unit (18 years old and younger), adults with Down syndrome 18 & up and parents/guardians are eligible to be a part of the Adopt-A-Family program. Please provide a detailed wish list (ranging from $35-$50 per person), including sizing for clothing items/shoes. DSA will not accept gift cards as an acceptable wish list item.

Gift Pick Up/Delivery Guidelines: Please be responsive in DSA’s attempts to contact you. Failure in response could forfeit your opportunity to receive gifts for your family. Your gifts can be picked up at the DSA office during the week of December 14th at a scheduled time OR can be delivered by a DSA team member, a volunteer, or the donor themselves.

DSA will review all applications submitted by the deadline of Friday, November 13, 2020. You will be notified when you have been matched with a donor. If you are matched, your gifts will be picked up the week of December 14, 2020 or delivered by a DSA team member, a volunteer, or the donor themselves.

Email *

By signing this application below, you attest that the information provided herein is true and accurate to the best of your knowledge. Should DSA need additional information related to this application but not provided herein, you agree to speak with a DSA employee and provide the additional information needed. Should your financial situation change, you agree to proactively disclose that change to DSA. If DSA learns that any of the information provided on this application or through subsequent conversations with DSA related to this application is false, or that you failed to disclose a material change in your situation, DSA has the right to revoke financial assistance and/or require you to remit financial assistance already provided by DSA.

First Name *

Last Name *

Address *

Email Address *

Phone Number *

How many adults are in your household? *

Adult #1 Name *

Adult #1 Employed? *

Yes

Other:

Adult #2 Employed?

Yes

Other:

Clear selection

Adult #3 Employed?

Yes

Other:

Clear selection

Please check ALL THAT APPLY:

Documentation of income is not required but may be requested if verification is necessary.

Please check ALL THAT APPLY: *

I am an existing DSA member that has a child with Down syndrome

My family's household income is at or below (numbers based on 200% of Federal Poverty Level guidelines) 1 person household / $25,520, 2 person household / $34,480, 3 person household / $43,440, 4 person household / $52,400, 5 person household/ $61,360, 6 person household / $70,320, 7 person household / $79,280, 8 person household / $88,240, additional persons, add $8,960 per person

I have extenuating circumstances or unforeseen conditions that significantly impacts my ability to pay for program costs. If so, please expand below.

Required

Please explain any extenuating circumstances.

I hereby declare that the above particulars and information availed above are true to the best of my knowledge and the same shall form the basis of any arrangement for any financial assistance, in any granted to me.

Name (First and Last) *

Date *

YYYY

Gift Pick Up / Delivery *

I would like to pick up our wrapped gifts at the DSA office during the week of December 14th (at a scheduled time).

I would like our wrapped gifts delivered by a DSA staff member, volunteer, or the donor themselves.

Family Wish Lists:

Please provide a DETAILED wish list (ranging from $35-$50 per person), including sizing for clothing and shoes. DSA will not accept gift cards as an acceptable wish list item.

Child or Adult with Down Syndrome's Name: *

Age: *

Gender: *

Ethnicity: *

Please provide a DETAILED wish list (ranging from $35-$50 per person), including sizing for clothing and shoes. DSA will not accept gift cards as an acceptable wish list item. *

Mother/Father/Guardian Name:

Gender

Ethnicity

Please provide a DETAILED wish list (ranging from $35-$50 per person), including sizing for clothing and shoes. DSA will not accept gift cards as an acceptable wish list item.

Mother/Father/Guardian Name:

Gender:

Ethnicity:

Please provide a DETAILED wish list (ranging from $35-$50 per person), including sizing for clothing and shoes. DSA will not accept gift cards as an acceptable wish list item.

Sibling #1 Name:

Age:

Gender:

Ethnicity:

Please provide a DETAILED wish list (ranging from $35-$50 per person), including sizing for clothing and shoes. DSA will not accept gift cards as an acceptable wish list item.

Sibling #2 Name:

Age:

Gender:

Ethnicity:

Please provide a DETAILED wish list (ranging from $35-$50 per person), including sizing for clothing and shoes. DSA will not accept gift cards as an acceptable wish list item.

Sibling #3 Name:

Age:

Gender:

Ethnicity:

Please provide a DETAILED wish list (ranging from $35-$50 per person), including sizing for clothing and shoes. DSA will not accept gift cards as an acceptable wish list item.

Sibling #4 Name:

Age:

Gender:

Ethnicity:

Please provide a DETAILED wish list (ranging from $35-$50 per person), including sizing for clothing and shoes. DSA will not accept gift cards as an acceptable wish list item.

Sibling #5 Name:

Age:

Gender:

Ethnicity:

Please provide a DETAILED wish list (ranging from $35-$50 per person), including sizing for clothing and shoes. DSA will not accept gift cards as an acceptable wish list item.

A copy of your responses will be emailed to the address you provided.

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