South East Leadership Academy booking form – South East Leadership Academy

Please select the programme/ event you want to book from the first drop down question.

Booking Form

Please select event you wish to book:*
Which date would you like to attend*

Wednesday 21st July 2021 09:00 – 12:30

Thursday 23rd September 2021 13:00 – 16:30
Please choose ONE session only. Places are limited and you will receive a confirmation email.
Which date would you like to attend*

Tuesday 7th December 2021 10:00 – 11:30
Bookings for the 20th October have now closed. Places are limited and you will receive a confirmation email.
Are you a:*
The Effective Patient Leadership Programme is designed for Patients, Carers and Lay members. The Reaching Out Programme is aimed at all staff working within Health & Social Care that have a responsibility for patient engagement and/or experience. Please note places are limited and you will receive a confirmation email.
First Name*
Surname*
E-mail Address*
Please state what NHS Region you are from*

East of England

London

North East and Yorkshire

North West

South East

South West

Midlands

I do not know

Other
If you selected Other for NHS Region, please specify:*
Please select your job role from the list below:*
If you selected Other for your job role, please specify:*
What is your occupational group?*
What is your occupational group? (AHPs / Healthcare Scientists / Scientific and Technical)*
What is your occupational group? (Medical and Dental)*
What is your occupational group? (Ambulance/ operational)*
What is your occupational Group/ (Registered Nurses and Midwives)*
What is your occupational group? (Social Care)*
What is your occupational group? (Wider Healthcare Team)*
What is your occupational group? (Other, please specify)*
Do you work or is your primary role in the following area of care:*

Primary

Secondary

Voluntary, community and social enterprise (VCSE) sector care

Social Care

Local Government

I do not wish to disclose

Unknown
Do you have face-to-face contact with patients / service users are part of your day job?*

Yes, frequently

Yes, occasionally

No
For NHS and Social Care staff – please select your Agenda for change band*
If you selected Other for Agenda for Change band, please specify:*
For non-NHS – please specify your organisation/career grading i.e. Administration/clerical, Management, Senior management, Board member, or Other/ Do not wish to disclose*
Organisation*
If you selected Other for Organisation, please specify:*
Please select the ICS your organisation is in*
If you selected Other for ICS, please specify:*
What are the two biggest challenges in your leadership across the PCN at the moment?*
What are your two biggest challenges around leading without authority at present?*
Thinking about your motivations, please identify one objective which you hope to achieve in attending this event.*
I confirm that I have my line manager’s support to attend this event.*

Yes

No (your form will not be accepted)
Please provide your line manager’s email address:*
This session may be recorded. Please confirm that you are in agreement with this?*

Yes

No
This event is funded by the South East Leadership Academy (SELA). By completing and submitting this form:*

Yes, I agree to these terms and conditions

No, I do not agree to these terms and conditions (your form will not be accepted)
*SELA will retain a record of your name, job role, organisation, band, and contact details on its secure alumni register and contacts database for management information and communications purposes. Read our Privacy Policy here. Although we will be able to see your name and email address upon submission, once extrapolated this data will be anonymised. We appreciate your support in providing this information, which will help us to ensure our leadership development interventions are widely accessible and inclusive.
*I am fully committed to attend and participate in this event. If my application is successful, I realise the importance of attendance and completing any preparatory coursework (if applicable).
*I understand that if asked, I will participate in post-event follow up and evaluation.

If you are successful and accept your place on this event, we will share:
your application details, in line with information governance and data protection guidelines, with the event provider and/or facilitator to allow them to understand participant thinking and adapt the event accordingly if required. your email address with your cohort participants and may also share it with the members of other relevant SELA networks to aid communication, sharing of good practice and support.
Please see our Privacy Notice. You can opt-out of these arrangements at any point by contacting us at england.selll@nhs.net.
Important Notice – Cancellation Policy*

Yes, I agree to the cancellation policy

No, I do not agree to the cancellation policy (your form will not be accepted)
In order to demonstrate best value to patients, the NHS and taxpayers, we need to ensure maximum attendance on leadership development opportunities and events.
Please view our Cancellation Policy as there will be a non-attendance charge to your employer/organisation should you secure a place and subsequently fail to meet any of these commitments.
How did you hear about this development opportunity? Please select any that apply.*
If you selected Other to the above question, please specify:*
I would like to receive the Leadership Dispatch with information about current programmes and courses offered by the South East Leadership Academy.*

Yes

No

I already receive Leadership Dispatch
Are you Alumni of the NHS Graduate Management Training Scheme?*

Yes

No
What was your intake year?*
Specialism*

General Management

Finance

Human Resources

Health Analysis

Health Informatics

Policy and Strategy Management
Would you be happy for us to contact you for further information?*

Yes

No

Thank you for completing our booking form. You will receive confirmation of your place after the closing date.