New Member Form Please enable JavaScript in your browser to complete this form.IRI New Membership requires all applicants to have current First Aid Certificate, Business Insurance, 100 CPD Points (New Graduates within 12 months are exempt) and a copy of your Qualification. See membership requirements for further details. PERSONAL INFORMATIONName *FirstLastGender *FemaleMaleNon-binaryPrefer not to sayDate of Birth *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920CONTACT INFORMATIONEmail *EmailConfirm EmailPlease enter it twice to ensure no typing errors.Phone *Address 1 *Address 2 (if needed)Town *Eircode (optional, but recommended)County *CarlowCavanClareCorkDonegalDublinGalwayKerryKildareKilkennyLaoisLeitrimLimerickLongfordLouthMayoMeathMonaghanNorthern IrelandOffalyRoscommonSligoTipperaryWaterfordWestmeathWexfordWicklowQUALIFICATION DETAILSPlease enter the full details of your qualification in REFLEXOLOGY here. You will need to upload a scan or photo of your certificate.Awarding Body *Enter the body which certified you (eg: ITEC, VTCT). Some schools self-certify. If that applies to you, enter the name of the school.Training School *Enter the name of the school where you trained. If this was also the certifying body you listed above, enter it again here.Date of Qualification *Certificate File UploadUpload a copy of your Reflexology Qualification here. Permitted formats are PDF, JPG, PNG, GIF. File size may not exceed 5MB.INSURANCEName of Insurance Company *Policy Number *Expiry Date *Does your policy specifically state that Reflexology is covered? *YESNOInsurance Policy Upload a copy of your Insurance Policy. Permitted formats are PDF, JPG, PNG, GIF. File size may not exceed 5MB.FIRST AIDDo you have a First Aid Certificate or a Healthcare Provider's Card? *First Aid CertificateHealthcare Provider's CardMedically Qualified - Employer Confirmation LetterPlease tick one box. Non medically trained must provide a valid First Aid Certificate. Please see requirements listed under Membership on www.reflexology.ie. Medically trained can provide either a BLS Provider Card as issued by the HSE or a Letter from Employer/HSE/Hospital stating that First Aid Training has been completed. These are all valid for 2 years from date of completion of training. Name of First Aid Training Company *Please provide the name of the compnay that provided the First Aid Training/BLS TrainingTitle of Cours as stated on First Aid Certificate/BLS Provider Card *Please provid the title of the course that your qualification relates to Expiry Date on First Aid Certificate *Please provide the expiry date as stated on your First Aid Certificate/BLS Provider CardType of Healthcare Provider Card *Only if you have a Healthcare Provider CardExpiry Date on Healthcare Provider CardOnly if you have a Healthcare Provider CardFirst Aid Certificate/BLS Provider Card/Employer Confirmation Letter *Upload a copy of your First Aid Certificate/BLS Provider Card/Employer Confirmation Letter. Permitted formats are PDF, JPG, PNG, GIF. File size may not exceed 5MB.Continuous Professional Development (CPD) Applicants who have graduated within 12 months are not required to complete this section. I confirm I have completed 100 CPD points for my new members application *YesNoLEGAL RECORDSHave you ever been convicted of, or is prosecution pending for, a criminal offence? *NOYESPlease provide detailsThis does not automatically exclude you from membership, we need to make an assessment.Are you currently on the Sex Offenders Register? *NOYESPlease provide detailsWEBSITE LISTINGAll approved IRI members have the option to be listed on our website. You do not have to use the same details as you gave us. For your safety, we recommend you have a separate phone and email just for your reflexology practice. Provide details as you want them on the site.Do you want to be listed on our website? *YESNOName for Public Viewing *FirstLastPublic PhonePublic Email (optional)Website / URL (optional)Name of Therapy Practice - if any (optional)Town *Please only list one townLEGAL AGREEMENTSYou must give formal consent to the following in order to be a member of the Irish Reflexologist's Institute.GDPR Agreement *I consent to having the Irish Reflexologist's Institute Ltd retain the information provided in this form. I understand it will be processed as needed for the operations of the Institute as determined by the governing committee, staff and IRI constitution. I understand this may include sharing details with Healthcare Insurance Providers.Code of Conduct Commitment *I agree to be bound by the Code of Conduct of the Irish Reflexologist's Institute Ltd.Insurance Commitment *I agree to always hold Public Liability and Malpractice Insurance which covers Reflexology while I am a member of the IRI.Declaration *I declare that all the information supplied in this form is true and accurate.PaymentDiscount CodeSorry that is not a valid Discount CodeMembership TypeGraduate (within the last 12 months) - € 50.00Full - € 120.00Total€ 0.00Credit Card *CardName on CardSingle ItemPrice: € 0.00EmailSubmit
