DATE________
 
NAME _______________________________________________________

ADDRESS ____________________________________________________

____________________________________________________

____________________________________________________

Telephone: (Home)______________________(Work)__________________

Email address ____________________________________________________

How did you hear of the Association? ________________________________________

Interest in joining the Association____________________________________________

_______________________________________________________________________

I agree/ do not agree to have my name, address and telephone number being included on a membership list circulated to members.

Signed __________________________________________

Please return with £10 subscription to

Irish Association for Gifted Children (IAGC)
An Óige Thréitheach (AOT)
Carmichael House
4 North Brunswick Street
Dublin 7
Contact Telephone: (01) 873 5702