The Rural Centre

The Rural Centre

The Rural Centre
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PEACEPLUS Cross Border Heritage Programme Registration Form

Full Name *

First

Last

Year of Birth *

Gender

Male
Female
Other
Prefer not to say

Phone Number *

Email Address *

Area

Community Background

CNR (Catholic/Nationalist/Republican)
PUL (Protestant/Unionist/Loyalist)
Other
Prefer not to say

History/ Heritage Group you represent (if applicable)

confidential Phone Area

Emergency Contact Details *

First

Last

Relationship

Phone Number

Your information will be kept confidential and used only for programme purposes and I agree to the following: *

I give my consent to participate in the PEACEPLUS programme and related activities.
I give permission for photographs/videos of me to be taken and used for programme promotion.

Date *

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