BLD Course Booking Form

Neurogenic Bladder (Male and SPC) - Select course date from dropdown options:
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 5303 83
BIC Number: BOFIIE2D

*Please reference your Name, Organisation and Course Code.

We do not currently accept credit card payments
Privacy and Personal Data * Required
- I have read and understood the Privacy Policy
Tick here to indicate that you have read and understand our Privacy Policy Privacy Policy, where it states how we treat your personal data.
CAPTCHA

Delegate Details