Florence Nightingale Foundation NHS 70 Nurses and Midwives Leadership Programme Application form Opening date: 13th July 2018 at 12.00hrs Closing date: 13th August 2018 at 12.00hrs Part 1 Personal Details Personal information Title Mr Mrs Miss Ms Other (please specify) First Name Last Name Known As NMC Registration Number Job Title NHS Band or equivalent NHS Organisation 2
Your Work Address Line 1 Your Work Address Line 2 Your Work City/Town Your Work Post Code Your Work Email Your Personal Email* Date of Birth Mobile Phone No. Twitter Name of Chief Executive or equivalent Email address of Chief Executive or equivalent LinkedIn Part 2 Professional and Higher Education Qualification Institution (name, city, country) Date commenced Major field of study 3
Part 3 Supporting Information Please briefly outline your current role, including main responsibilities. 300 words max Please outline why are you applying to become a Florence Nightingale Foundation Nurse or Midwife (NHS 70) and explain how the programme will support your development. Please include your aspirations to develop as a leader. 4
Please outline how you will use this experience to improve patient and health outcomes. Part 4 Terms and conditions Terms and conditions 1) All applications submitted for the selection process must be accompanied by this completed application form signed by your line manager. 2) I will agree to be an Alumnus of the Foundation on completion of my scholarship (current annual subscription 50). 3) Florence Nightingale Foundation holds all participants application details in confidence and in line with the requirements of the Data Protection Act 1998 to ensure GDPR compliance. Cancellation policy As a not-for-profit organisation it is crucial that Florence Nightingale Foundation recover any programme costs in the event of a participant cancellation. Therefore, by accepting a place on this programme you will commit to attend all programme days. Agree terms and conditions Please sign below to accept terms and conditions: Name Date 5
Part 5 Diversity Form We are keen to develop diversity in all areas. By completing this form you are helping us to build a picture of those applying and attending our programmes. The information collected is stored on our database and not shared with any third parties. Your responses to this form will in no way affect your application process. Nationality (Please tick one box only and specify country of origin) British North America European (Non- British) South America Middle East Africa South Asia South Africa Australasia Please specify country of origin Ethnicity (Please tick one box only) White/White British White Other (please specify) Mixed/Dual Heritage Mixed Asian South Asia East Asia Any other mixed/multiple ethnic background (please specify) South East Asia Other (please specify) Black African Caribbean background Any other Black/African Other (please specify) Other Ethnic Group Arab Any other ethnic group Prefer not to say: 3
Religion (Please tick one box only) Buddhist Hindu Muslim Jewish Sikh Christian Other (please specify) Prefer not to say Gender (Please tick one box only) Male Female Prefer not to say Age bracket (Please tick one box only) 18 to 24 25-34 35-44 45-54 55-64 65 and over Prefer not to say Part 6 - Programme administration In order to stimulate the networking process for participants, we ask that you send us a short biography along with your answers to the three questions below. Please note: Biographies and answers will be edited for consistency and style. Short biography No longer than 150 words. Include information on your current and previous roles and interests. Write in the third person. Clarify any abbreviations used. 4
Emergency contact details Contact name Telephone no. Relationship Mobile no. Special Requirements None Halal Vegetarian Kosher Vegan Gluten Free Coeliac Other dietary requirements or food allergies: Do you have a: Disability Y N Medical Condition(s) If yes, please provide details: Home address Address Line 1 Address Line 2 City/Town Post Code Country 5