Online DSOSN Application Donation Amount ($25 minimum) * $1,000 $500 $250 $100 $50 $25 (minimum) Other If Other, please enter amount here: $ Yes, I want to sponsor a family(s) with an additional donation of $25 or Other $ * Yes No If Yes, please enter amount here: $ Date (Fecha) * Relationship to Person with Down Syndrome * Parent Family Member Supporter First Name (Nombre) * Last Name (Apellido) * Spouse/Significant Other's Name Address (Domicillo) * City (Ciudad) * State (Estado) * Zip (Codigo Postal) * Cell Phone * Home Phone Work Phone Fax Email Address (Dirección de Correo Electrónico) * Are you bilingual? (Si es plurilingue?) * Yes No If yes, what language(s) and *would you be willing to assist with translations? (Idiomas que habla y si estaria dispuesto a ayudar con traducciones?) Name(s) of Individual(s) with Down Syndrome (Individuo con Sindrome de Down - Nombre) * Age (Edad) * Birth Date (Fecha de Nacimiento) * Sibling(s) Name(s) and Age(s) [Nombre(s) y Edad(es) de Hermano/a(s)] Services you would be willing to offer DSOSN (Advertising, Public Relations, Legal, Medical, Financial, Administrative, Plumbing, Electrical, Carpentry, Volunteer, other) (Servicios que estaria dispuesto a ofrecerle al DSOSN) Please list below any of our fundraiser events that you would like to either serve as a committee member, chair or volunteer. Ex: Festival of Trees & Lights, Buddy Walk, Socials, Poker Runs, Monday’s Dark. Members must be in good standing with the DSOSN by March 31, 2018 to receive benefits, attend socials and vote at Annual Membership meeting in April.Media Waiver I grant permission to Down Syndrome Organization of Southern Nevada (hereinafter “DSOSN”) to use my likeness or image in any format, including but not limited to photographs, portraits, audio and/or video, for use in DSOSN related publications including but not limited to videos, emails, letters, brochures, newsletters, reports, calendars, pamphlets, magazines, and promotional materials, and to use my likeness or image in electronic versions of the same publications or on the DSOSN website or other electronic forms of media including but not limited to text messages, SMS, MMS, mobile apps, and any social media services such as Facebook, Twitter, or LinkedIn. I hereby waive any right to inspect or approve the photographs or electronic matter that may be used in conjunction with any DSOSN publication now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or relating to the use of my likeness or image. * I see no objection to my child/family having his/her pictures/videos, and/or name(s) used in connection with the Down Syndrome Organization of Southern Nevada I object to my child/family being photographed/video recorded. Please sign by typing in your full name. * HOLD HARMLESS AGREEMENT I, the undersigned, agree to assume all risk of accident, injury, illness, or loss that may occur at, during, or in connection with any activity related to DSOSN. I further agree to hold DSOSN harmless and release DSOSN from any and all legal claims which I may have for any expenses, damages, injuries, or losses arising from any activity related to DSOSN. I understand that DSOSN provides services which benefit me, either directly or indirectly, and that my participation in activities related to DSOSN constitutes satisfactory consideration for this agreement. * YES NO Please sign by typing in your full name. * TRANSPORTATION WAIVER I understand that if, while in connection with any activity held, promoted, conducted, sponsored, ran, organized, or operated by or in conjunction or partnership with (hereinafter collectively “related to”) Down Syndrome Organization of Southern Nevada (hereinafter “DSOSN”), I am operating or riding in a private passenger vehicle which is involved in an accident, I will be covered for bodily injury under the primary insurance policy covering that vehicle, including any applicable secondary or umbrella coverage on that vehicle, and I agree to submit any claims in connection with the accident to said insurance company(ies). If the policy has been issued with a deductible clause relative to the liability coverage, I understand that I am responsible for that deductible. I understand that if, while I am operating or riding in a commercial carrier or other leased or rented vehicles in connection with any activity-related to DSOSN and an injury occurs, I shall look to the commercial carrier’s applicable primary, secondary, umbrella, and any other related liability coverage and/or to the owner and/or operator of the leased or rented vehicle to pay any expenses or damages incurred as a result of such accident, injury, or loss. * YES NO Please sign by typing in your full name. * You can make your Donation by clicking the PayPal button below. Thank you.