Membership Form

If you wish to be come a member you can download the membership form below or you you can join up or renew your membership online by filling in the form below. The system uses Paypal but will happily accept normal credit / debit cards without the need for a Paypal account.

Membership Form (download and post to us)

Please note - we will retain the information contained on this form and all other data you provide to the organisation while you continue to be a member. Once you cease to be a member, unless you request that we delete your data, we will retain it for a further period of 5 years. The data will be placed in an archive after 2 years and completely deleted 5 years after you cease to be a member.

Fields marked (*) are required, but as much information as possible is helpful. Your information is never shared with third-parties without your express consent.

Type:*
New Membership
Membership Renewal

Name:*

Address:

Telephone:

Email:*

Category:*
Parent of Child with Dyspraxia €30
Adult with Dyspraxia €30
Professional €35
Other €30

Do you require a receipt?

Adult

Date of Birth:

Age(s) at Diagnosis:

Any other relevant information:

Parent

Please tell us about your child

Boy
Girl

Name of Child/Children:

School(s) Attending:

Date of Birth:

Age(s) at Diagnosis:

Speech Difficulties:

What services are you receiving?:

Any other relevant information:

Professional

Your Profession:

Ages of children you are in contact with:

Additional Donation:
€
If you would like to make an additional donation to the association we would very much welcome your contribution (please use whole numbers only, anything after a decimal point will be disregarded)

Membership Form

Adult

Parent

Professional

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