Florence Nightingale Foundation Leadership Scholarship Application form Closing date: 14 th September 2018 at 17.00hrs Leadership scholarship level Please indicate which scholarship level you wish to be considered for: Senior leadership scholarship Aspiring Nurse Director / Midwife Director scholarship Emerging Leaders scholarship 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 Band/Grade Employing Organisation 1
Your Work Address Line 1 Your Work Address Line 2 Your Work City/Town Your Work Postcode Your Work County Your Work Country England Wales Scotland N. Ireland Southern Ireland Your Work Phone. No Your Work Email Your PA name (if applicable) Your PA email address (if applicable) Your PA phone number (if applicable) Your Personal Email* Date of Birth Mobile Phone No. Twitter Name of Chief Executive Email address of Chief Executive LinkedIn Address Work City/Town Work Postcode Work County Your Work Country England Wales Scotland N. Ireland Southern Ireland Financial details if different from above Purchase number (if required) 2
Have you benefitted from Florence Nightingale funding previously Yes No *This enables us to keep in touch with you if you should move organisations. Part 2 Professional and Higher Education Qualification Institution (name, city, country) Date commenced and completed Subject matter area 3
Part 3 Supporting Information Organisation information Your organisation s sector: NHS Independent Please specify sector Charity Military Please specify company Education Other If other, please specify: The size of your organisation s workforce 0 to 49 50 to 249 250 to 999 1,000 to 9,999 10,000+ Annual turnover: Up to 1million 1-10 million 10-100 million 100-1 billion 1 billion + Please tell us about the size of your team, the number of people you currently lead (or number of direct reports) and your budget responsibility (if applicable). (300 words max) 4
Please briefly outline your current role, highlighting any specific operational and strategic responsibilities. (300 words max) Part 4 Personal leadership What have been the key points of your experience of leadership to date? (300 words max) 5
What are your leadership aspirations over the next five years and how will a scholarship with the Foundation help you achieve these? (500 words max) Have you applied for leadership development funding in the last 12 months? If so, please state the organisation, the amount applied for and your personal learning. (300 words max) 6
Part 5 Terms and conditions Terms and conditions PLEASE READ CAREFULLY 1) All applications submitted for the selection process must be accompanied by a fully completed application form, and signature of your organisational sponsor which must be the Chief Executive or the Director of Nursing. In addition we require confirmation from your sponsor will support the 10% employer s contribution. 2) You will be notified about the outcome of interview approximately by the first week of December 2018. You must confirm your acceptance in writing two weeks after the receipt of your offer letter. If successful, an invoice will then be issued to your organisation. Payment is required within 30 days of the issue of the invoice and prior to attendance, unless agreement under exceptional circumstances. We are unable to give refunds. 3) The 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. 4) You will be required to submit an interim report, a final report and a publication of your improvement project. The latter must be submitted no later than six months following the completion of your scholarship. 5) In accepting the offer of a scholarship you will agree to be an Alumnus of the Foundation on completion of your scholarship. The current annual subscription 50 and the first payment will be due on completion of your scholarship. Cancellation policy As a not-for-profit organisation the Florence Nightingale Foundation has the right to recover any programme costs in the event of a participant cancellation. By accepting a scholarship you are committing to attend every event associated with the scholarship. Agree terms and conditions I agree to the terms and conditions as set out above: Name Date 7
Part 6 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) European Middle British (Non- East British) North America South America Africa South Asia South Africa Australasia Irish 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 Please specify Prefer not to say: 8
Religion (Please tick one box only) Buddhist Hindu Muslim Jewish Sikh Christian Prefer not to say Other (please specify) Gender (Please tick one box only) Male Female Prefer not to say Age (Please tick one box only) 18 to 24 25-34 35-44 45-54 55-64 65 and over Prefer not to say Part 7 - 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 Email address 9
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 10