Application Form Please enable JavaScript in your browser to complete this form.I confirm that I have read and accept the booking terms and conditions. *YesIf you are free to travel any time or at short notice if a cancellation occurs, please tick here.I can travel any time or at short noticePlease select the start date of your preferences for Tramore, Tralee or Killarney below. More detailed information on each location will be forwarded when booking is confirmed. All holidays start on Saturdays. You can select a date for more than one location. Please only select dates between the available months for each home, selecting any other dates may delay your application. Available months: Tramore: April 2022 - October 2022 Tralee: May 2022 - April 2023 Killarney: May 2022 - April 2023Tramore Date Selection – 5 night basisTralee Date Selection – 5 night basisKillarney Date Selection – 5 night basisWhich is your preferred location? *Select preferenceTramore (6 person apartment)Tramore (4 person apartment)Tralee (8 person house)Killarney (4 person house) Have you previously had an IKA Holiday in Tramore, Tralee or Killarney? *YesNoWhen did you last have a holiday in Ireland or abroad? Month and year is enough if you can't recall exact dates.DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920If you wish to avail of financial support, please tick yes.YesPatient name *FirstLastEmail *Contact Number *Secondary Contact NumberAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodePrimary treating hospital or clinic *Select hospital or dialysis unitB.Braun Wellstone GalwayB.Braun Wellstone PortlaoiseB.Braun Wellstone WexfordBeacon Renal DroghedaBeacon Renal SandyfordBeacon Renal TallaghtBeaumont HospitalBelfast City HospitalBlackrock ClinicBon Secours Health System GalwayCavan General HospitalChildren's Health Ireland CrumlinCork University HospitalDaisy Hill Hospital NewryFresenius KilkennyFresenius LimerickFresenius Northern CrossGalway ClinicLetterkenny University HospitalMayo University HospitalMercy University Hospital CorkMerlin Park University Hospital GalwayMidland Regional Hospital PortlaoiseMidland Regional Hospital TullamoreSligo University HospitalSt James's Hospital DublinSt John's HospitalSt Vincent's Hospital DublinTallaght University HospitalTemple Street Children's University HospitalThe Coombe Women & Infants University HospitalThe Mater Misericordiae University HospitalThe National Maternity HospitalThe Ulster Hospital BelfastUniversity Hospital KerryUniversity Hospital LimerickUniversity Hospital WaterfordCurrently treated by *HDPDTransplanted (TX)Including yourself, how many people would be staying in our accommodation? *Select numberJust me2345678Please give the names, ages, and relationship to patient of any accompanying people. *If you or your accompanying guests have any special needs please bring them to our attention (e.g. drip stand, visually impaired, wheelchair, commode etc.)Submit