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MENUMENU
  • What is EB?
  • Home
  • About Us
    • About DEBRA Ireland
    • Governance and Management
    • Our impact reports and financial accounts
    • Our Promise
    • What is EB?
    • Our Ambassadors
    • Celebrity Champions
    • DEBRA International
  • What We Do
    • Family Support
      • Young people with EB
      • EB Cards
      • Real Life Stories
      • The Butterfly Garden
      • Meet the Team
      • Family Support Services
      • Health Entitlements
      • The Hospital Referral Process
    • Research
      • EB Research in the News
      • DEBRA Ireland’s Involvement in Research
      • Patient and Public Involvement
      • EB Patient Registries
      • Clinical Research
      • DEBRA Ireland Research Committee
    • Awareness & Advocacy
      • Working together for rare diseases
      • Improving health entitlements
      • Improving care
      • Progressing the development of therapies
      • Our Future
  • Get Involved
    • Gifts in Wills
      • Gifts in Wills
    • Fundraising
      • Facebook fundraising
      • Other Ways to Donate
      • Corporate Fundraising
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      • Kerry Challenge 2023
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  • Family Support Service – Registration Form

Family Support Service – Registration Form

Step 1 of 7

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  • Please note: We can only accept applications from people who have been affected by EB. This will include people who are diagnosed with EB, family members of those diagnosed with EB and family members who are bereaved. If you have any queries around this, please do not hesitate to contact us at [email protected]
  • Section 1: Personal Details

  • This is not a requirement however, allows us to offer more tailored support to you and your family.
  • (optional)
  • (You can select more than one if applicable)
  • Full NameDate of BirthGenderRelationship to ApplicantDo they have EB? 
  • Section 2: Support

  • To help us understand how best you would like to be supported at this time, please answer the following:

  • Section 3: Supporting Documentation

  • To fully support you and your family and offer you the full range of our EB support services, we require a letter from your EB clinic or General Practitioner (GP) confirming you have EB and the type of EB. This will allow us to appropriately support you.

  • Alternatively, you can email this to [email protected] at a later date
    Drop files here or
    Max. file size: 64 MB.
    • Section 4: Data Protection Act - Personal Data Consent Form

    • Permission to store your personal data:

      In order for DEBRA Ireland to comply with General Data Protection Regulation (GDPR) and to provide you with the best service, we are required to obtain your explicit consent to the processing of certain special category personal data such as health data and to obtain your consent to receiving certain information from DEBRA Ireland.


      Please tick yes or no to the following questions:

    • MM slash DD slash YYYY

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    Contact Us

    DEBRA Ireland,
    Butterfly Cottage
    8 Clanwilliam Terrace
    Grand Canal Quay
    Dublin 2

    Tel: +353-1-412-6924
    E: [email protected]
    Registered charity number: 8703
    Charity regulator number: 20021726

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