Epilepsy Ireland

If you already have an account, please click here to login before completing this form.

Thank you for your interest. So that we can assist you with your enquiry, please complete and submit the form below. Please note that by completing and submitting this form, you are giving us your consent to securely pass on your information to Epilepsy Ireland, and a free membership account will be created for you on our website.

Event

Do you already have an entry in this event?

Confirm Email

First name

Last name

Phone number We ask for your telephone phone number as a secondary form of contact. It is not mandatory, but may prove to be helpful as part of your application. Your phone number will only be used in relation to this application and will not be passed on to third parties.

Why do you want to participate?

Fundraising target: €1000

Although €1,000 is our preferred minimum fundraising target it is not the sole criteria for selection. Please add the amount that you think you can successfully fundraise along with some supporting notes for review by our fundraising team. If successful, you will also need to pay a €110 registration fee and will be contacted by a member of our fundraising team to arrange.

How much do you pledge to fundraise?

How will you meet your fundraising goal?

By clicking on the Submit button below:

You confirm that the information you have provided above is true and correct

You confirm that you are 18 years of age or over

I confirm that I have read and agree with our Terms of Use and Privacy Policy.