<p> The Social and Health Education Project Cork Short Community Education Courses Autumn 2015 Application Form</p><p>Applicant’s Name: Home Address: Work Address: </p><p>Home Phone: Work Phone: Mobile Phone:______E-mail Adress:______</p><p>Where did you hear about the courses? ______If referred to the course by another person please specify? ______Do you have any special needs/medical needs that we should be aware of for practical purposes? Please specify:______Where applying for a course for which there is No Charge, if it applies to you, please provide a copy of a recent welfare payment, as some priority in allocating places will be given to this. I wish to apply for the following course/s Autumn Venues – The Lantern (Georges Quay, Cork City Centre), Ballincollig & 2015 Blackrock. Please Tick the course/s you are applying for √  Intro. to Personal Development (The Lantern Thursdays 7.00 to 9.30pm) – No Charge □  Effective Communication (The Lantern Tuesdays 10.30-1.00pm) – No Charge □  Men's Wellbeing (The Lantern Tuesdays 7.00pm to 9.30pm) – No Charge □  Women's Health & Wellbeing (The Lantern Wednesdays 10.30-1.00pm) – No Charge □  Introduction to Personal Development (SHEP Ballincollig Mon 7.30- 10) - €75 □  Managing Stress in Our Daily Lives (SHEP Ballincollig Wed 7.30-10) – No Charge □  Living with Grief, Loss & Change (SHEP Blackrock Wed 7.30-10pm) - €75 □  Caring for Our Wellbeing (SHEP Blackrock Tuesdays 7.30-10pm) – No Charge □  Effective Communication (SHEP Ballincollig Mondays 7.30-10pm) - €75 □  Supporting Yourself as a Parent (SHEP Blackrock Thursdays 7.30-10pm) – No Charge □  Applications are only processed when submitted on a completed Application Form.  Where a course fee applies, the €75 is to be enclosed with the application form  Generally places are allocated in order of application and courses run subject to numbers applying. You will be notified in advance whether you have secured a place  All courses at No Charge are Subject to Funding  SHEP treats information gathered via this form confidentially, storing it electronically and in hard copy, and using it internally for the purpose of training course management and programme evaluations. Signature:______Date:______</p><p>Please return this Application Form to Programme Administrator, The Social and Health Education Project, Village Chambers, Village Centre, Station Road, Ballincollig, Co. Cork (021-4666180)</p>