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



First Name (required)

Last Name (required)

Age

Education

Spouse's Name

Spouse's Age

Spouse's Education

Address

State

City

Postal Code

Phone: Home

Phone: Work

Your Email (required)

GENERAL INFORMATION



Occupation

Other parent/spouse Occupation

Number of Children

Total pregnancies Living

Miscarriage(s)





CHILD INFORMATION



Name

Birth Date

Age

Sex
MaleFemale

Education




Please Indicate Current Program



Regular education classroom

Special education classroom

Home schooling or other

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

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

MyelomeningoceleMyeloceleOcculta/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/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


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

The biggest challenge for you or / having a child with spina bifida

The greatest gift this child (if in children) has brought to our lives is

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..