Family Care Fund – Down Syndrome Association of the Upstate

First Name *Person completing this application

Last Name *Person completing this application

Are you the parent or caregiver for the individual needing support? *YESNO

If you answered NO, please give the parent or caregivers name below.

Are you currently enrolled in a DSAU membership? *YESNODisclaimer: In order to receive supports from the Family Care Fund, applicants must be enrolled in a DSAU membership. If the person completing the application is not the parent or caregiver but is a family member or friend, the benefiting family must have an active DSAU membership. Enrollment can be completed either before or after submitting this application; however, enrollment must be finalized prior to the disbursement of any supports. If the family is unable to complete the registration themselves a trusted family member or friend can complete the registration for them.

Individual with Down Syndrome being hospitalized first & last name *

Age of individual with Down Syndrome being hospitalized? *

Street Address *Home address for the individual with Down Syndrome, used for delivering supports when the hospitalization is preplanned.

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone *Parent/Caregiver contact phone number

Email Address *Parent/Caregiver email address

Date hospitalization started or is projected to start? *

Was this an emergent hospitalization (e.g., medical emergency, accident, etc.)? *YESNO

Is there an expected duration of hospitalization? *YESNO

If there is an expected duration of hospitalization, how long has the physician told you to expect? *Medical emergency – duration of hospitalization is uncertain.1 night2-3 nights4-6 nights7 nights1-2 weeks2+ weeks

Is the individual with Down Syndrome undergoing a surgical procedure? *YESNO

If they are undergoing a surgical procedure, what kind of procedure will they be having?You are not required to disclose the exact procedure being performed, only the specialty field that will be conducting the surgery (e.g., cardiology, ENT, etc.). This helps us understand what type of supports might be most beneficial, such as soft snacks like pudding or jello, or cozy comfort items for those on sternum precautions, etc.

What hospital system is or will the individual with Down Syndrome be hospitalized in? *

If presently hospitalized, what care floor is the individual currently on and what is their room number?

Will the individuals family be traveling for care? *YESNO

Will the individuals family be utilizing the Ronald McDonald House for lodging? *YESNONot Applicable

Will the individuals family be utilizing a hotel for lodging needs? *YESNONot Applicable

Are there siblings in the home? *YESNO

If there are siblings within the home, how many are there?Disclaimer: Asking about family size allows us to provide more accurate meal supports tailored to the family's needs, especially if a meal train needs to be established.

What types of supports would be most benefical to the family at this time? *Coffee gift cards for parents/caregiversMeal gift cardsGas cards for traveling to and from the hospitalHygiene care packageSnack care packageGift for the individual with Down SyndromeMeal train creation to further expand supports for the family by encouraging their friends and loved ones to help provide meals during this time.Laundry servicesParking passes (length of hospitalization must be longer than 2+ weeks and out-of-state or MUSC care)Please check all supports that may be beneficial; however, understand that not all supports may be granted. The duration of hospitalization will determine the amount/types of support the Family Care Fund can offer.

What is the best method of delivery for supports (e.g. in person delivery, hospital drop off, digital gift cards)? *

Would you like a prayer request created to inform the community? *YESNO

Would you like a DSAU outreach representative to contact you for emotional support during this time? *YESNO