Number of Children Attending:* Please select 1 2 3 4

Emergency Contact Name:*

Emergency Telephone Number:*

Your Email:*

Your Name:*

Contact Telephone Number:*

Relationship to Children:* Please select Parent or Guardian Other family member Other, please specify below

County of residence* Please select Carlow Cavan Clare Cork Donegal Dublin Galway Kerry Kildare Kilkenny Laois Leitrim Limerick Longford Louth Mayo Meath Monaghan Offaly Roscommon Sligo Tipperary Waterford Westmeath Wexford Wicklow Antrim Armagh Derry Down Fermanagh Tyrone Great Britain EU Other

Home Address:*

Are there any additional details about your child's strengths or needs you would like to share that will support a positive experience during the event:*

Any allergens or medical requirements:*

In order to process your registration and to support your child's experience at this event, it is necessary for us to share the information provided in this form with the event-host/organiser and event coaches. I consent to the sharing of the information contained in this form with the event host/organiser and event coaches:*

Where appropriate (and with the consent of the children's parents/guardians) the event-host/organiser and/or Dyspraxia DCD Ireland may wish to use photos, videos and/or recordings of the children (taken during the event) on their respective websites, social media channels and publications. I consent to the use of images/media of my child by the event-host/organiser and Dyspraxia DCD Ireland: (optional)