Cottage Autism Network
+353 087 1035 355
info@cottageautismnetwork.com / cottageautism@gmail.com

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NOTE: IF YOU ARE USING A MOBILE DEVICE TO COMPLETE THIS FORM PLEASE TURN IT SIDEWAYS TO SEE ALL FIELDS TO BE FILLED.



Please provide contact details for two people who may be booking a child into, or accompanying a child to an activity. Should any details change throughout the year, please let us know.


Child(ren)'s Details: Please provide the following information about your child(ren)

Information: Membership Fee is €26 (including processing fees) per calendar year i.e. January to December (this means that members are required to renew their membership every January and those that join CAN at any time during the year are required to renew their membership in January. All data records are stored confidentially and only used by Cottage Autism Network Wexford to disseminate information to our members. Member information is not shared with third parties without prior consent.

Additional information

Your order

Product Subtotal
C.A.N - 3 Year Membership  × 1 65.00
Subtotal 65.00
Total 65.00

Your personal data will be used to process your order, support your experience throughout this website, and for other purposes described in our privacy policy.