Family & Friends NB Course Booking Form

Select the Course Option below: * Required
Delegate Details
Name * Required
First Last
Job Title
Email address * Required
Contact Number * Required
Complete following section only if attending in-person courses:
Special dietary, access, or other requests
Special diet, or allergies
Accessibility requests
Assistive Technology
Other, please specify
Organisation
Billing Address * Required
Address Town County Eircode
Billing Contact Name * Required
Email * Required
Payment Method
Please Select One * Required
- Purchase Order
- Bank Transfer (EFT)
Purchase Order (PO Number) OR Electronic Fund Transfer (EFT) Number * Required

* Please Reference your Name, Organisation and Course Code on the PO or EFT
Amount: € * Required
Bank: Bank of Ireland Dun Laoghaire, Co. Dublin
Account Name: National Rehabilitation Hospital
Account Number: 83538083
Sort Code: 901116
IBAN Number: IE59 BOFI 9011 1683 5380 83
BIC Number: BOFIIE2D

*Please reference your Name, Organisation and Course Code.
Privacy and Personal Data * Required
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Tick here to indicate that you have read and understand our Privacy Policy Privacy Policy, where it states how we treat your personal data.
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Delegate Details