Form

West Cork Educate Together SECOND-LEVEL Campaign

Expression of Interest Form
Educate Together is currently collecting Expressions of Interest from parents who want an Educate Together Secondary School in West Cork.

This data will be used in the event of the Department of Education opening a process whereby potential school patrons apply for patronage.

Please be aware that this does not guarantee that a school will open in West Cork or that the chid/ren named will be offered a place if a school is opened.
Parent/Guardian 1 Full Name *

First Name Last Name
E-mail
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Parent/Guardian 2 Full Name

First Name Last Name

Address *

Street Address
Street Address Line 2
Town/City	County
EIRCODE (available at www.eircode.ie)	Country

Email
Preferred medium of instruction *
CHILD 1
Child 1- Full Name *

First Name Last Name
Child 1 - Date of Birth *

- Day - Month Year
Child 1 - Year Starting School *
CHILD 2
Child 2 - Full Name

First Name Last Name
Child 2 - Date of Birth

- Day - Month Year
Child 2 - Year Starting School
CHILD 3
Child 3 - Full Name

First Name Last Name
Child 3 - Date of Birth

- Day - Month Year
Child 3 - Year Starting School
CHILD 4
Child 4 - Full Name

First Name Last Name
Child 4 - Date of Birth

- Day - Month Year
Child 4 - Year Starting School
CHILD 5
Child 5 - Full Name

First Name Last Name
Child 5 - Date of Birth

- Day - Month Year
Child 5 - Year Starting School
Would you like to subscribe to the Educate Together Network Newsletter

Yes, subscribe me to this newsletter.
I understand that this information may be made available to the Department of Education and Skills (DES) in order to plan for school development.

(Please note: No guarantee of places is given or implied by registering an expression of interest.)
Name

First Name Last Name
Should be Empty:

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