This application form is for the 2013 SHEP Certificate in Social Awareness and Community Empowerment course (SHEP Foundation Course 2) in Kerry, which will consist of five non-residential weekend workshops between September and December 2013. Based in Collis Sandes House, Tralee the dates of the weekends are:

·  Friday 13th September evening only

·  Saturday 14th September

·  Sunday 15th September

·  Saturday 5th October

·  Sunday 6th October

·  Saturday 2nd November

·  Sunday 3rd November

·  Saturday 16th November

·  Sunday 17th November

·  Saturday 7th December

·  Sunday 8th December

A certificate of participation will be awarded on satisfactory completion of the course.

Completion of both foundation courses is necessary for entry to the Facilitation and Specialised Practitioner Training courses run by SHEP. Admission to these courses will be subject to availability of places and selection will be on the basis, both of the quality of involvement in the Foundation Courses, and of the nature of the voluntary or professional work with people that applicants are engaged in (or plan to be engaged in).

Name of Applicant: ______

Home Address: ______Work Address: ______

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Home Phone: ______Work Phone: ______

Mobile Phone: ______E-mail address: ______

Which address for correspondence? (Pease tick) Home: Work:

Date of birth: ______Occupation: ______

Relevant voluntary work (if any) ______

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What is your interest in doing this course? ______

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How/where did you hear about the course? ______

Have you completed any previous courses on any aspect of health-education, personal development or group work? Please specify

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Do you have any special needs that we should be aware of for practical purposes? Please specify

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Is there any other information about yourself that you would like on file?

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The total cost of the SHEP Cert in Social Awareness and Community Empowerment course (2013) is €450. A booking deposit of €100 (made payable to The Social and Health Education Project), should accompany this form (returnable only if a place is not offered). When a place is offered, and before the course begins, the remainder of the fee should be paid. For those who wish, special arrangements may be made to spread payments over the duration of the course. A concessionary rate of €250 will be available to those who are: (a) in receipt of a social welfare payment, (b) in full-time study, (c) on minimum wage or in low-paid employment, or (d) experiencing financial hardship. If you wish to apply for the concessionary rate, please complete the concession rate form and return it along with the completed application form to the address below.

I wish to apply for the SHEP Cert. in Social Awareness and Community Empowerment for 2013.

I enclose a deposit of €100 or if applying for concessionary rate, I enclose €50 deposit and

the completed concession form

Signature: ______Date: ______

The application closing date is

Friday August 16th 2013

Please complete this form and return it together with a cheque or money order in respect of your deposit to: The Programme Administrator, The Social & Health Education Project, Village Centre, Station Road, Ballincollig, Co.Cork.

For further information phone 021 466 6180 or 087 772 8089