Membership Form

(Print out Form and fill it in)

Name of applicant / organisation / group in Block capitals

_____________________________________________________________________________

Please tick appropriate box:

Panel A   People with disabilities over 18 years old

Panel B   Parents/ Partners/ Relatives of disabled person(s)

Panel C   Advocates of persons with a disability

Panel D   National organisations      

ADDRESS_____________________________________________________________________________

______________________________________________________________________________________

TELEPHONE NO: _____________________________________________

EMAIL:  _____________________________________________

Tick if you are 18 or over

Male               Female


Name of Illness / Disability

_____________________________________________________________________________

Illness / Disability is classed as:

Sensory disability
Physical disability
Learning disability .
Mental/Emotional disability
Chronic illness disability

Other _______________________________________________________

Do you require a Sign Interpreter?  Yes          No

Please specify if you require a special format for correspondence:
Disk              Audio Cassette              Braille            Large Print         Email 
        

If the group/ organisation is affiliated to a National Organisation please specify:

_________________________________________________________________________

I agree to become a member of National Council for People with Disabilities and to support its Aims and Objectives.

Signature: ___________________________________   Date: ________________________

N.B. Groups/Organisations: Please enclose description of activities and a copy of Constitution or Memorandum and Articles of Association with your application if available

National Council for People with Disabilities complies with Data Protection Acts 1988, 2003.

Mailing Address

National Headquarters

National Council for People with Disabilities

29 Ballycaseymore

Ballycasey

Shannon town

Co. Clare

Ireland