We have drafted this register to collate as much information about Heart Children as possible.  We would be grateful if you could help.  It will help us to target the needs of both children and parents and would give a clearer picture for the future.

It would especially help to know your child’s name and date of birth.  

Please add on any other information you would like us to know.  Everything will be in strictest confidence.  

If you would like to contact or be contacted by another parent with similar problems please let us know (there will be no contact unless verified by phone first).

Even if you have filled in a form before – update us!

Please return to: Linda Hogan
                       Administrator,
                       The Carmichael Centre, North Brunswick Street, Dublin 7
Telephone:        1850 217 017
Email:               heartchildren@eircom.net
Web site:          www.heartchildren.ie

Heart Children
Register of Member Children’s Details

Family Name: *

Child’s Name: *

Date of Birth: *

Day12345678910111213141516171819202122232425262728293031

MonthJanFebMarAprMayJunJulAugSepOctNovDec

Year198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032

Parents Names: *

Address: *

Email address: *

Telephone: *

Child’s Condition: *

Comments/Notes/ Other Information: *

Word verification: * (verify using audio)

Type the characters you see in the picture above; if you can't read them, submit the form and a new image will be generated. Not case sensitive.