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 you/your child in our Association.

PARENT/INDIVIDUAL INFORMATION

GENERAL INFORMATION

CHILD INFORMATION

Sex
MaleFemale

PLAESE INDICATE CURRENT PROGRAM

What type of Spina Bifida do you/your child have ?

MyelomeningoceleMyeloceleOcculta/Lipoma

PLEASE CHECK ALL ITEMS THAT BEST DESCRIBE YOUR CHILD/INDIVIDUAL.

Mobility:
Normal for ageWalks independentlyWalks with crutchesWalkerCrawlsBears weightWheelchairNo mobility

Toilet Skills:
Normal for ageIn DiapersOnly at nightCatheterizedCan Cath selfIn TrainingWill always need diapers

Vision:
NormalImpairedBlindSees lightContact Lenses

Speech:
Normal for AgeDifficult to understandNonverbal Communication

Diet/Eating Skills:
Normal for AgeRegular dietSpecial diet

Hearing:
NormalImpairedDeafReads LipsWears Hearing Aides Range of HearingRight earLeft ear

Behavior:
Typical for ageHyperactiveOverly AffectionatePassiveSelf-AbusiveImpulsiveAggressiveDefiant

Please check the correct boxes :

You may let another parent/individual whose child/they themselves has a similar disorder call me to talk.I would like information about any support group for my/my child's disorder.You may release my name to people interested in contacting families about research involving my/my child's condition.Please do not release the above information to anyone!You may print my name & address if required anywhere..