Address:  29 Ballycaseymore, Ballycasey, Shannon town, Co. Clare   Web:  Email:   Phone:  086 2313272  Company number: 533165  Charity number: 20227   Tax number:  3207504LH

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      



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: ________________________

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


Shannon town

Co. Clare