Information Session Request Form

This form can be used to make a request for EPIC to provide an information session about our services to children and young people, staff teams, foster carers or students.

This session will be facilitated based on availability of staff in your area, who will contact you directly to schedule a suitable meeting time.

Please complete the form fully. Fields marked with a * are required.

Person Filling out the form

Select one that describes your role:

College/Universtiy Name

Your First Name

Your Last Name

Your Mobile number

Your Direct number
(if different from Mobile)

Land line or Mobile phone

Your Email

Your Role/Job title

Your Organisation

Residential Unit Name

Parent Organisation

Please select one option

Address Line 1

Address Line 2

Address Line 3

County

EIRCODE

Please click here to find EIRCODE

Organisation's Phone number

Land line or Mobile phone

Your College/University

College/University Name

Address Line 1

Address Line 2

Address Line 3

County

EIRCODE

Please click here to find EIRCODE

College/University Website

Your Contact Details

Gender

Your Birthdate

Your Address (Line 1)

Your Address (Line 2)

Your Address (Line 3)

Your County

Your EIRCODE

Please click here to find EIRCODE

Session Details

Number of People Session is for

Numbers only [eg, 2, 3, 4, 5, .....]

Is this request for a young person in a Special Emergency Arrangement (SEA)

Any other information

Your privacy is important to us and this form is sercured with strong SSL encyption. By submitting this form, you agree to send this information to EPIC, where it will be processed in accordance with our Privacy Statement

Yes

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Contact Information