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Membership  form  for  Indian Spina Bifida Association


 Indian Spina Bifida Association will help in bringing together the families and care providers of all affected with Spina Bifida; so that they can share their views, experiences and resources with each other. Parents will find it very useful to join ISBA, where they can meet other families with similar needs. ISBA can serve many purposes, but primarily they offer parents a place and a means to share information, give and receive emotional support, and work as a team to address common concerns.

 All questions are optional and are asked only for purpose of better understanding.

 

No information will be released without your permission, therefore we need this information before we can register your child in our Association.

 

 

PARENT/FAMILY INFORMATION

First Name: Last Name:

 Age :

 Education :
 Spouse's Name:
Age :   Education :
Address :  State :
 City: Postal Code:
Phone : Home:    Work :
Email:

GENERAL INFORMATION
Occupation : Other parent's Occupation:
 

Number of Children:
Total pregnancies Living       Miscarriage(s)

 

CHILD INFORMATION
Name:
Birthdate: Age :
Sex :        Male Female   
Education:

 

 

Please Indicate Current Program
Regular education classroom
Special education classroom
Home schooling or other :
 

Please indicate other therapy that your child receives: as Physiotherapy etc. 

 

What type of Spina Bifida does your child have ?
Myelomeningocele Myelocele Occulta/Lipoma
 

What level ? For example T5, or L4

 

  

Secondary Conditions associated with Spina Bifida :
Birth weight :
 Medications taken presently :
Medications taken in the past:
 

 

Please check all items that best describe your child.
 

 Mobility:
                 Normal for age Walks independently
                 Walks with crutches Walker
                 Crawls Bears weight
                 Wheelchair No mobility
                  

Toilet Skills:
                 Normal for age In Diapers
                 Only at night Catheterized
                 Can Cath self In Training
                 Will always need diapers
 


Vision:
                 Normal Impaired
                 Blind Sees light
                 Contact Lenses

Speech:
                 Normal for Age Difficult to understand
                 Nonverbal Communication
                  
 
Diet/Eating Skills:
                 Normal for age   Regular diet
                 Special diet

Hearing:
                 Normal Impaired
                 Deaf Reads Lips
                 Wears Hearing Aides Range of Hearing Right ear
                 Left ear

Behavior:

                 Typical for age Hyperactive
                 Overly Affectionate Passive
                 Self-Abusive Impulsive
                 Aggressive Defiant
 

Hospitalizations/Surgeries: ( related to your child's disability) List Hospital and date.

 

The biggest challenge with having a child with spina bifida

 

The greatest gift this child has brought to our lives is

 

Please check the correct boxes :

1. You may let another parent whose child has a similar disorder call me to talk.

2. I would like information about any support group for my child's disorder.

3. You may release my name to people interested in contacting families about research involving my child's condition.

4. Please do not release the above information to anyone!

5. You may print my name & address if required anywhere..

    

  

Thank you, For becoming a member of this Association.

 Vinita Jindel, G - 14, Krishna Marg,

C' Scheme, Jaipur-302001

Contact # 91-141- 2365528, 91-141- 2377042

email : vinita@indiaspinabifidaassociation.org