The Social and Health Education Project

Cork Short Community Education Courses

Autumn 2015 Application Form

Applicant’s Name:

Home Address: Work Address:

Home Phone: Work Phone:

Mobile Phone:______E-mail Adress:______

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 2015 / Venues – The Lantern (Georges Quay, Cork City Centre), Ballincollig & 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:______

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)