Inclusion Ireland - Membership Individual Application Form




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	INDIVIDUAL APPLICATION FORM


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Membership: Individual Application Form

Please fill in the form below, or you can download it here and print it and post it back to us: Inclusion Ireland, Unit C2, The Steelworks, Foley St, Dublin 1.

Name:
Address:
Telephone:
Mobile:
Email(Username):
Password:
Note: Please choose a password so you can log into member only areas of the site and renew your membership online in the future.

My interest in intellectual disability is as a (please tick):
Person with an intellectual disability
Parent of a person with an intellectual disability
Relative of a person with an intellectual disability
Professional (please specify)
Member of local association (please specify)

Issues of particular interest to you (please tick):
Early Intervention
Education
Respite
Waiting Lists
Staffing Issues
Benefits & Allowances
Rare Syndromes
Challenging Behaviour
Legal Issues
Research
Other

How did you hear about Inclusion Ireland?

Please note once your application has been approved the annual fee of €40 will be due.

Inclusion Ireland, Unit C2, The Steelworks, Foley Street, Dublin 1, Ireland. Tel: 01 8559891 Fax: 01 8559904 Email: info@inclusionireland.ie