New Member Form Please enable JavaScript in your browser to complete this form.Please complete this Membership Application form to join the IRI. You will need to upload a scanned copy of your Qualification Certificate.PERSONAL INFORMATIONName *FirstLastGender *FemaleMaleNon-binaryPrefer not to sayDate of Birth *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920CONTACT 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? *YESNOFIRST AIDDo you have a First Aid certificate or a Healthcare Provider's Card? *First Aid CertificateHealthcare Provider's CardI am not qualified to give first aidName of First Aid course providerOnly if you have a First Aid certificate.Title of course as stated on your First Aid certificateOnly if you have a First Aid certificate.Expiry Date on First Aid certificateOnly if you have a First Aid certificate.Type of Healthcare Provider CardOnly if you have a Healthcare Provider CardExpiry Date on Healthcare Provider CardOnly if you have a Healthcare Provider CardLEGAL 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(s) *You can only be listed once. If you list more than one town, we will print them all in your listing, but your listing will be placed under the first town you provide.LEGAL 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.NameSubmit
