EmailMe Form - Cohort 10 Application Form

Cohort 10 Application Form

Leadership for Empowered Communities and Personalised Care -
Cohort 10 Application Form

This application form helps us check your suitability for the Leadership for Empowered Communities and Personalised Care (LECPC) Programme.

Please complete all sections below and return the completed application form to Lynsey Oates at applications@leadershipforpersonalisedcare.org.uk
as soon as possible but before 5pm Friday 16th December 2022.

Please note that the following criteria will be used for selection:
• alignment of personal objectives for the programme to programme objectives
• demonstration of commitment to personal leadership development
• demonstration of commitment to meeting the challenge of making personalised care a reality
• freedom to act and implement learning from the programme in current role
• ability to attend all the face-to-face and virtual workshop dates (see section 3 for the list)
• acceptance of the cancellation policy (see section 3 for details)

Selection will be carried out by a virtual panel. We will contact you to advise if you have been successfully accepted onto the programme as soon as possible after the closing date (above).

Please answer all the questions below in typed format. Feel free to expand the form to suit your answers.
This is your form description. Click here to edit.

SECTION 1: ABOUT YOU
Please tell us who you are
Name *
First Last
Title (Mr, Ms, Dr etc)
Employer/Practice *
Address for correspondence (please indicate if work/home) *
Postcode *
Work mobile
Work Telephone
Work Email (this is the
email we will contact you on throughout the programme,
if you are successful) *
NB If your application is successful, the above contact information will be shared with your programme colleagues, facilitators and with programme partners, to enable invitations to related events.

Confirm
SECTION 2: BIOGRAPHICAL INFORMATION

Job Role Information and Supporting Information
Current role start date *
Previous role title and length of service *
Please outline below why you wish to undertake this programme, identifying any specific outcomes you wish to achieve for you personally, for your employer and for the people and communities you support
Please outline relevant continuing professional development (CPD) you have undertaken in the last three years?
Please outline how you intend to implement what you will learn
Specific Requirements:
Please let us know of any dietary requirements
Specific Requirements:
Please let us know of any access or learning requirements
Section 3: YOUR COMMITTMENT
1. Dates
I confirm that I would like to apply for the Leadership for Empowered Communities and Personalised Care Programme and that I am able to attend all the face to face and virtual modules (webinars) as listed below.

Face to Face – All of these sessions will take place between 9.00 – 5.00pm:
• Thursday 26th January, London
• Wednesday 8th & Thursday 9th March, Loughborough
• Thursday 27th April, London
• Wednesday 7th June, London
• Thursday 6th July, London

There will also be virtual meet and greets and webinars between the face to face sessions.

2. Fees and cancellation
I agree to the terms and conditions and the penalty fees for non-attendance of any part of the programme as detailed below.

Programme fees – All fees must be paid in full before the start of the programme.
Fees cover refreshments, meals and programme materials but do not include travel to or from the programme venues, or accommodation if you choose to travel overnight.

Cancellation and transfer fees – All nominations must relate to the individual applicant. Once your place is confirmed to you, the following terms and conditions apply:

• More than 30 days’ notice – no charge will apply
• Less than 30 days’ notice – a cancellation charge of 50% of the programme cost will be applied
• No show/not attendance – a penalty charge of £2,000 plus VAT will be applied
Invoicing
I agree for the nominated person below to be invoiced a fee of £800 plus VAT

Contact details for invoicing

Name *
Title *
Department / Service Area
Organisation *
Postal Address *
Postcode
Work Telephone
Work Email *
Personal Data

Please note that we respect your privacy and are committed to protecting your personal data.

We will use your personal data to:
• Share with the LECPC programme team to assess your suitability against the acceptance/recruitment criteria
• Share with the LECPC programme team to understand participant thinking and adapt the programme accordingly if required
• If you are successful and accept your place on the programme, we will share your contact details with other participants on the programme, and with other cohorts of the programme if this is required i.e. to build a network
• If you are successful and accept your place on the programme, we will contact you (via email and phone) to share information about the structure and content of the programme
• If you are successful and accept your place on the programme, we will invite you via email, to participate in post-programme impact evaluations
• If you are successful and accept your place on the programme, we will invite you to alumni events and share other future opportunities. If you do not want us to store and use your data for this purpose, please let us know

I agree to all the above terms and conditions
Clear
please sign above or type your name below to confirm *
Date

SECTION 1: ABOUT YOU

SECTION 2: BIOGRAPHICAL INFORMATION

Section 3: YOUR COMMITTMENT