Mary Seacole Application Form Mary Seacole programme application form 2024 We would recommended you click ‘Save and Continue Later’ button to avoid your application being lost as you proceed through the questions. 1Privacy Agreement2About you3Cohort4Employment Information5Funding6Equality, Diversity & Inclusion7Personal Statement8Keeping in touch9Terms and Conditions10Summary Application-IDHiddenSubmission Date DD dash MM dash YYYY Privacy Agreement Any information you provide in completing this application will be stored and processed in accordance with our Data Privacy Policy which you are required to read and accept before completing your application. By proceeding with this application, you agree that The Leadership Academy may contact you if you have partially completed your application to offer guidance and support with finishing your application. This is a separate agreement to the marketing preferences selected further in this application.Please check the box below to accept the above agreement and our Data Privacy Policy(Required) I confirm I have read and accept the Academy’s Data Privacy Policy and above agreement Please note this form is closed and applications will not be countedAbout youName(Required) First Last Preferred Name Preferred Email(Required) Your primary email addressPreferred contact number(Required) Your main contact number with international dialling code and extension if necessaryDate of Birth DD dash MM dash YYYY Please enter your 10-digit Academy ID(Required)If you already have an Academy ID, please log on to our new Academy Profile system using your existing log in details to ensure your account is transferred to our new system. If you need help remembering your existing Academy ID, please use the Reset password feature on the Profile system. If you do not have an Academy ID, please register on our Academy Profile system to create one. Home address Street Address Address Line 2 City ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Region(Required)East of EnglandLondonMidlandsNorth East and YorkshireNorth WestSouth EastSouth WestWalesScotlandNorthern IrelandNon-UK Please see the dates for your Cohort Start date – 13/09/2022 Workshop 1 – 11/10/2022 Workshop 2 – 06/12/2022 Workshop 3 – 31/01/2023 End date – 14/03/2023 Please note this is the application form for the Commissioned Cohort 107. If you do not believe you should be applying for this cohort, please contact your administrator. Otherwise, click next. Please see the dates for Cohort 107 Below Start date – 28/04/2022 Workshop 1 – 26/05/2022 Workshop 2 – 21/07/2022 Workshop 3 – 22/09/2022 End date – 27/10/2022 Please note this is the application form for the Commissioned Cohort 108. If you do not believe you should be applying for this cohort, please contact your administrator. Otherwise, click next. Please see the dates for Cohort 108 Below Start date – 05/05/2022 Workshop 1 – 09/06/2022 Workshop 2 – 28/07/2022 Workshop 3 – 29/09/2022 End date – 03/11/2022 Please note this is the application form for Together Training Mary Seacole Cohort 1. If you do not believe you should be applying for this cohort, please contact your administrator. Otherwise, click next. Please see the dates for Cohort 1 Below Start date – 14/11/2022 Workshop 1 – 12/12/2022 Workshop 2 – 23/01/2023 Workshop 3 – 27/03/2023 End date – 19/05/2023 Please note this is the application form for the Commissioned Cohort 127. If you do not believe you should be applying for this cohort, please contact your administrator. Otherwise, click next. Please see the dates for Cohort 127 Below Start date – 31/10/2022 Workshop 1 – 29/11/2022 Workshop 2 – 24/01/2023 Workshop 3 – 07/03/2023 End date – 24/04/2023 Cohort Participants on this programme are divided into cohorts. Each cohort has a number of events which you must be able to attend. You can see details of available cohorts on this web page. Attendance at all cohort events is mandatory. Please check the dates and locations of workshops and other events on the web page link above and then select your preferred cohort below:Preferred Cohort(Required) Cohort 145 (Nottingham) Start: 17/06/2024 Workshop 1: 16/07/2024 Workshop 2: 03/09/2024 Workshop 3: 31/10/2024 End: 13/12/2024 Cohort 147 (Northampton) Start: 15/07/2024 Workshop 1: 13/08/2024 Workshop 2: 01/10/2024 Workshop 3: 28/11/2024 End: 10/01/2024 Cohort 149 (Nottingham) Start: 16/09/2024 Workshop 1: 16/10/2024 Workshop 2: 03/12/2024 Workshop 3: 30/01/2025 End: 14/03/2025 There are currently no cohorts availableCohort Please see the dates for Cohort 15 below: Start Date – 21st June 2023 Workshop 1 – 27th July 2023 Workshop 2 – 21st September 2023 Workshop 3 – 15th November 2023 End Date – 25th December 2023 West Mids Cohort Please see the dates for Cohort 5 below: Start Date – Wednesday 20 October 2021 Workshop 1 – Wednesday 17 November 2021 Workshop 2 – Wednesday 12 January 2022 Workshop 3 – Wednesday 09 March 2022 End Date – Wednesday 20 April 2022 CandP Please see the dates for Cohort 20 below: Start Date – 2nd March 2023 Workshop 1 – 27th April 2023 Workshop 2 – 25th May 2023 2023 Workshop 3 – 6th July 2023 2023 Cohort 15 Please see the dates for Cohort 15 below: Start Date – 16 May 2022 Workshop 1 – 27 June 2022 Workshop 2 – 18 August 2022 Workshop 3 – 26 September 2022 End Date – 14 November 2022 Lancashire and South Cumbria Please see the dates for Cohort 16 below: Start Date – 29/09/22 Workshop 1 – 18/10/22 Workshop 2 – 13/12/22 Workshop 3 – 07/02/23 End Date – 29/03/23 Cheshire and Mersey Please see the dates for Cohort 27 below: Start Date – 13th October 2022 Workshop 1 – 23rd November 2022 Workshop 2 – 5th January 2023 Workshop 3 – 15th February 2023 End Date – 13th April 2023 London Licence Please see the dates for Cohort 4 (GOSH) below: Start Date – 7th May 2024 Workshop 1 – 23rd July 2024 Workshop 2 – 10th September 2024 Workshop 3 – 29th October 2024 End Date – 19th November 2024 Greater Manchester Cohort Please see the dates for Cohort 39 below: Start Date – 12 September 2022 Workshop 1 – 17 October 2022 Workshop 2 – 30 November 2022 Workshop 3 – 12 January 2023 End Date – 13 March 2023 South Warwickshire Cohort 31 Please see the dates for Cohort 31 below: Start Date – 16th Jan 2023 Workshop 1 – 23 Feb 2023 Workshop 2 – 11th April 2023 Workshop 3 – 8th June 2023 Lincolnshire Cohort Please see the dates for Cohort 31 below: Start Date – 5th June 2023 Workshop 1 – 5th July 2023 Workshop 2 – 12th September 2023 Workshop 3 – 31st October 2023 End Date – 4th December 2023 Leeds Teaching Hospitals Cohort Please see the dates for Cohort 09 below: Start Date – 08/02/23 Workshop 1 – 22/03/23 Workshop 2 – 10/03/23 Workshop 3 – 28/06/23 End Date – 09/08/23 Local Herts Wessex Cohort 16 Cohort 17 Start: 05/03/2024 Workshop 1: 16/04/2024 Workshop 2: 06/06/2024 Workshop 3: 22/07/2024 Cohort 18 Start: 17/04/2024 Workshop 1: 15/05/2024 Workshop 2: 17/07/2024 Workshop 3: 11/09/2024 Local Lincolnshire Cohort Cohort 32 Start: 04/09/2023 Workshop 1: 05/10/2023 Workshop 2: 28/11/2023 Workshop 3: 25/01/2024 Cohort 33 Start: 06/11/2023 Workshop 1: 06/12/2023 Workshop 2: 22/02/2024 Workshop 3: 17/04/2024 Local Derbyshire Cohort 19(Required) Cohort 19 Start: 23/04/2024 Workshop 1: 21/05/2024 Workshop 2: 16/07/2024 Workshop 3: 10/09/2024 End: 22/10/2024 Cohort 20 Start: 17/05/2024 Workshop 1: 14/06/2024 Workshop 2: 09/08/2024 Workshop 3: 04/10/2024 End: 15/11/2024 Leeds Teaching Hospital Cohorts(Required) Cohort 16 Start: 06/02/2024 Workshop 1: 19/03/2024 Workshop 2: 30/04/2024 Workshop 3: 18/06/2024 Surrey Heartlands Cohorts(Required) Cohort 15 Start: 20/05/2024 Workshop 1: 26/06/2024 Workshop 2: 20/08/2024 Workshop 3: 09/10/2024 South East Cohort Please see the dates for Cohort 03 below: Start Date – 7th Nov 2022 Workshop 1 – 16 Dec 2022 Workshop 2 – 10th Feb 2023 Workshop 3 – 31st March 2023 End Date – 12th May 2023 Local South East Preferred Cohort(Required) Cohort 9 Start: 16/04/24 Workshop 1: 01/05/24 Workshop 2: 26/06/24 Workshop 3: 04/09/24 End: 22/10/24 Local Frimley Preferred Cohort(Required) Cohort 21 Start:08/02/2022 Workshop 1: 22/03/2022 Workshop 2: 11/05/2022 Workshop 3: 07/07/2022 End: 15/08/2022 Cohort 22 Start:03/05/2022 Workshop 1: 07/06/2022 Workshop 2: 04/08/2022 Workshop 3: 19/09/2022 End: 13/10/2022 Cohort 23 Start:13/06/2022 Workshop 1: 04/07/2022 Workshop 2: 05/09/2022 Workshop 3: 17/10/2022 End: 05/12/2022 Cohort 24 Start:13/09/2022 Workshop 1: 11/10/2022 Workshop 2: 13/12/2022 Workshop 3: 07/02/2023 End: 13/03/2023 Local Leeds and York Preferred Cohort(Required) Cohort 31 Start: 23/04/2024 Workshop 1: 21/05/2024 Workshop 2: 16/07/2024 Workshop 3: 10/09/2024 End: 22/10/2024 Local Essex Preferred Cohort(Required) Cohort 21 Start: 20/07/2023 Workshop 1: 06/09/2023 Workshop 2: 12/10/2023 Workshop 3: 20/11/2023 End: 22/01/2024 Local Nottinghamshire Preferred Cohort(Required) Cohort 16 Start: 17/04/2023 Workshop 1: 24/05/2023 Workshop 2: 12/07/2023 Workshop 3: 06/09/2023 End: 22/10/2023 Cohort 17 Start: 17/04/2023 Workshop 1: 25/05/2023 Workshop 2: 18/07/2023 Workshop 3: 21/09/2023 End: 22/10/2023 Local Cheshire and Mersey Cohort(Required) Cohort 38 Start: 22/04/24 Workshop 1: 16/05/24 Workshop 2: 04/07/24 Workshop 3: 05/09/24 End: 17/10/24 Cohort 39 Start: 15/05/24 Workshop 1: 13/06/24 Workshop 2: 01/08/24 Workshop 3: 03/10/24 End: 15/11/24 Local Hereford and Worcester Cohort(Required) Cohort 11 Start: 24/05/2024 Workshop 1: 27/06/2024 Workshop 2: 08/08/2024 Workshop 3: 19/09/2024 End: 21/11/2024 Cohort 12 Start: 28/06/2024 Workshop 1: 24/07/2024 Workshop 2: 20/09/2024 Workshop 3: 07/11/2024 End: 07/01/2025 Local Northumbria Cohort(Required) Cohort 02 Start: 22/05/2024 Workshop 1: 03/06/2024 Workshop 2: 05/08/2024 Workshop 3: 07/10/2024 End: 18/11/24 Local North East Cohort(Required) Cohort 25 Start: 06/05/24 Workshop 1: 1a – 19/06/24 / 1b – 26/06/24 Workshop 2: 2a – 14/08/24 / 2b – 21/08/24 Workshop 3: 3a – 02/10/24 / 3b – 09/10/24 End: 20/11/2024 MMU – Apprenticeships Local License Preferred Cohort(Required) Cohort 16 (Sept 2023 Manchester) Start: 23rd September 2024 Workshop 1: 7th October 2024 Workshop 2: 21st October 2024 Workshop 3: 4th November 2024 Cohort 17 (Oct 2023 London) Start: 2nd October 2024 Workshop 1: 16th October 2024 Workshop 2: 30th October 2024 Workshop 3: 13th November 2024 Cohort 18 (Oct 2023 Birmingham) Start: 10th October 2024 Workshop 1: 24th October 2024 Workshop 2: 7th November 2024 Workshop 3: 21st November 2024 Cohort 19 (Jan 2024 Cambridge) Start: 16th January 2025 Workshop 1: 30th January 2025 Workshop 2: 13th February 2025 Workshop 3: 6th March 2025 Cohort 20 (May 2024 Leeds) Start: 7th May 2025 Workshop 1: 14th May 2025 Workshop 2: 11th June 2025 Workshop 3: 9th July 2025 Cohort 21 (May 2024 Manchester) Start: 12th May 2025 Workshop 1: 3rd June 2025 Workshop 2: 16th June 2025 Workshop 3: 30th July 2025 Cohort 22 (May 2024 London) Start: 13th May 2025 Workshop 1: 27th May 2025 Workshop 2: 17th June 2025 Workshop 3: 8th July 2025 Greater Manchester Local License Cohort(Required) Cohort 48 Start: 20/05/2024 Workshop 1: 24/06/2024 Workshop 2: 05/08/2024 Workshop 3: 23/09/2024 End: 20/11/2024 Cohort 49 Start: 08/05/2024 Workshop 1: 19/06/2024 Workshop 2: 18/07/24 Workshop 3: 22/08/2024 End: 08/11/2024 South Warwickshire Local License Cohort(Required) Cohort 39 Start: 03/06/24 Workshop 1: 09/07/24 Workshop 2: 11/09/24 Workshop 3: 06/11/24 Lancashire and South Cumbria Local License Cohort(Required) Cohort 22 Start: 14/03/2024 Workshop 1: 20/05/2024 Workshop 2: 02/07/2024 Workshop 3: 05/09/2024 End: 14/11/2024 BPP – Apprenticeships Local License Preferred Cohort(Required) ODM L5 with Mary Seacole Feb 2024 – Cohort 16 Start: 25th March 2024 Workshop 1: 23rd May 2024 Workshop 2: 10th December 2024 Workshop 3: 13th February 2025 End: 15th June 2025 Royal Devon – Apprenticeships Local License Preferred Cohort(Required) Cohort 3 Mary Seacole Start: 10th June 2024 Workshop 1: 10th July 2024 Workshop 2: 21st August 2024 Workshop 3: 29th October 2024 End: 12th December 2024 Pearson – Local License Preferred Cohort(Required) CMI Accreditation Cohort 4 Induction: 9th April 2024 Workshop 1: 20th May 2024 Workshop 2: 22nd July 2024 Workshop 3: 30th September 2024 Workshop 4: 9th December 2024 End of Cohort: 31st January 2025 Pearson – Apprenticeship Cohort(Required) ODM Apprenticeship: Mary Seacole Cohort 1 Start: 4th December 2023 Workshop 1: 24th January 2024 Workshop 2: 17th July 2024 Workshop 3: 13th February 2025 End date (assignment submission): 30th June 2025 STUK- Apprenticeship Local License Preferred Cohort(Required) (March 2023 Cohort 8) Mary Seacole Cohort 1 Mary Seacole Start: March 2023 Workshop 1: 18th July 2023 Workshop 2: 17th October 2023 Workshop 3: 9th January 2024 End: 9th April 2024 Lighthouse Group – Apprenticeship Local License Preferred Cohort(Required) Cohort 1 Start: 28th February 2024 Workshop 1: 4th April 2024 Workshop 2: 5th June 2024 Workshop 3: 26th August 2024 End: 2nd October 2024 Employment Information Please enter the details of your current main job role.Organisation Region(Required)East of EnglandLondonMidlandsNorth East and YorkshireNorth WestSouth EastSouth WestWalesScotlandNorthern IrelandNon-UKCountry(Required)AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwePlease select your countryOrganisation Name(Required) To be able to access all of our features, you need a browser that supports JavaScript, and it needs to be enabled. The name of your organisation Primary Role APPLIANCE CONTRACTOR APPLICATION SERVICE PROVIDER APPLICATION SERVICE PROVIDER – LEGACY BRANCH SURGERY CANCER NETWORK CANCER REGISTRY CARE TRUST CARE TRUST SITE CLINICAL COMMISSIONING GROUP CLINICAL COMMISSIONING GROUP SITE CLINICAL NETWORK COMMISSIONING SUPPORT UNIT COMMISSIONING SUPPORT UNIT SITE COMMON SERVICE AGENCY (CSA) CONSTABULARY COURT DATA SERVICES FOR COMMISSIONERS REGIONAL OFFICE (DSCRO) DIRECTLY MANAGED UNIT (DMU) DISTRICT HEALTH AUTHORITY (DHA) DMU SITE DSCRO SITE EDUCATION EXECUTIVE AGENCY EXECUTIVE AGENCY PROGRAMME EXECUTIVE AGENCY PROGRAMME – DEPARTMENT EXECUTIVE AGENCY SITE GENERAL DENTAL PRACTICE GOVERNMENT DEPARTMENT GOVERNMENT DEPARTMENT SITE GOVERNMENT OFFICE REGION HEALTH AUTHORITY (HA) HEALTH OBSERVATORY IMMIGRATION REMOVAL CENTRE INDEPENDENT SECTOR H/C PROVIDER SITE INDEPENDENT SECTOR HEALTHCARE PROVIDER ISLE OF MAN GOVERNMENT DEPARTMENT ISLE OF MAN GOVERNMENT DIRECTORATE ISLE OF MAN GOVERNMENT DIRECTORATE SITE LOCAL AUTHORITY LOCAL AUTHORITY – LEGACY LOCAL AUTHORITY DEPARTMENT LOCAL AUTHORITY SITE LOCAL AUTHORITY SITE – LEGACY LOCAL HEALTH BOARD LOCAL HEALTH BOARD SITE LOCAL SERVICE PROVIDER (LSP) LSP SITE MILITARY HOSPITAL NATIONAL APPLICATION SERVICE PROVIDER NHS ENGLAND (REGION, LOCAL OFFICE) NHS ENGLAND (REGION, LOCAL OFFICE) SITE NHS ENGLAND (REGION) NHS SUPPORT AGENCY NHS TRUST NHS TRUST SITE NON STATUTORY NHS ORGANISATION NON-NHS ORGANISATION NORTHERN IRELAND GP PRACTICE NORTHERN IRELAND HEALTH & SOCIAL CARE BOARD NORTHERN IRELAND HEALTH AND SOCIAL CARE TRUST NORTHERN IRELAND LOCAL COMMISSIONING GROUP OPTICAL HEADQUARTERS OPTICAL SITE OTHER STATUTORY AUTHORITY (OSA) OTHER STATUTORY AUTHORITY SITE OTHER UNIT (IN SUPPORT OF NHS BUSINESS) PATHOLOGY LAB PHARMACY PHARMACY HEADQUARTER PHARMACY SITE POLICE CUSTODY SUITE PRESCRIBING COST CENTRE PRIMARY CARE GROUP PRIMARY CARE NETWORK PRIMARY CARE TRUST PRIMARY CARE TRUST SITE PRISON REGIONAL OFFICE (RO) SCHOOL SCOTTISH GP PRACTICE SCOTTISH HEALTH BOARD SECURE CHILDREN’S HOME SECURE TRAINING CENTRE SEXUAL ASSAULT REFERRAL CENTRE SOCIAL CARE PROVIDER SOCIAL CARE SITE SPECIAL HEALTH AUTHORITY (SPHA) SPECIAL HEALTH AUTHORITY SITE STRATEGIC HEALTH AUTHORITY SITE STRATEGIC PARTNERSHIP WELSH ASSEMBLY WELSH LOCAL HEALTH BOARD WELSH LOCAL HEALTH BOARD SITE YOUNG OFFENDER INSTITUTION OTHER The primary role of your organisation Postcode The postcode of your organisation Is this an NHS organisation?(Required) Yes No HiddenOrganisation CountryEnglandNorthern IrelandScotlandWalesOutside UK Organisation Type Organisation Name HiddenOrganisation Type Please enter the type of organisationHiddenNew OrganisationHidden section that is only shown when the organisation is unknownHiddenOrganisation Name Please enter the name of the organisationHiddenOrganisation Post Code Please enter the post code of the organisationHiddenDoes this organisation provide any NHS-funded care?(Required) Yes No Don’t know HiddenRole(Required) Staff GroupAdditional Clinical ServicesAdditional Professional Scientific and TechnicalAdministrative and ClericalAllied Health ProfessionalsEstates and AncillaryHealthcare ScientistsMedical and DentalNursing and Midwifery RegisteredStudent Job Title Area of work(Required)Primary careAcute trustMental health trustCommunity careCommissioningOccupational HealthPublic HealthSocial CareCorporateOtherJob Title(Required) Please enter your job titleSalary/Band(Required)Band 1Band 2Band 3Band 4Band 5Band 6Band 7Band 8aBand 8bBand 8cBand 8dBand 9Band VSMOther Salary/BandDo not wish to discloseCurrent?(Required) Yes No Are you currently active in this role? Please note: we only require past roles if you are unemployed.Number of years within your role(Required) Number of years working in the UK(Required) Which of the funded places are you applying for?(Required)Pharmacy Technicians Funding If you are part of a commissioned or local cohort, then you are not required to complete this section. Please feel free to continue by clicking next below.Funding You are applying for a place that is fully funded by NHS England and Improvement as part of the Growing Occupational Health programmeFundingThe Mary Seacole programme costs £995 per person. The cost is fully inclusive of the three virtual workshops and access to the virtual campus. If you intend for your organisation to fund your place on this programme, please do not continue with this application unless funding has been secured in agreement with your line manager. How will your place on the programme be funded?(Required)Please indicate the method you will use to fund your place on the programme. If you are sharing the cost with your organisation then choose the second option as you will be responsible for obtaining the funds from your organisation. Please check with your line manager or finance team if you are unsure how your place will be funded. Please check with your line manager or finance team if you are unsure how your place will be funded. An organisation will be funding my place I will be funding my place Does this organisation provide NHS funded care?(Required) Yes No Internal Transfer? Yes Check this box if your organisation is eligible to pay by direct internal cost-centre transfer rather than invoice. If in doubt, leave this box unchecked and we will invoice you.Budget holder email address(Required) If you are being funded by your organisation please note the email address of your budget holder (or other authorised person) above. If you are self-funding please note your main email address used in the ‘about you’ section. Equality & Diversity We hold the principles of equality and inclusion at the heart of everything we do and all that we stand for. Each programme is held to account for its inclusion practice through a review of anonymised statistics based on this data. Your equality and diversity data is not used to determine the success of your application. This data is stored securely in compliance with the General Data Protection Regulation (GDPR) 2016.Which of the following best describes your gender?(Required)FemaleMaleUnknown GenderDo not wish to discloseAre you now or have you ever defined yourself as Trans?(Required)YesNoDo not wish to discloseWhich of the following best describes your sexual orientation?(Required)Heterosexual or StraightLesbianGayBisexualAsexualOther sexual orientation not listedUndecidedDo not wish to discloseWhich of the following best describes your ethnic background?(Required)White – BritishWhite – IrishWhite – Any other White backgroundMixed – White and Black CaribbeanMixed – White and Black AfricanMixed – White and AsianMixed – Any other Mixed backgroundAsian or Asian British – IndianAsian or Asian British – PakistaniAsian or Asian British – BangladeshiAsian or Asian British – Any other Asian backgroundBlack or Black British – CaribbeanBlack or Black British – AfricanBlack or Black British – Any other Black backgroundOther ethnic groups – ChineseOther ethnic groups – Any other ethnic groupDo not wish to discloseWhich of the following best describes your religion or belief system?(Required)AtheismBuddhismChristianityHinduismIslamJainismJudaismSikhismNot religiousOtherDo not wish to discloseWhich of the following best describes your nationality?(Required)AfghanAlbanianAlgerianAmericanAmerican SamoanAndorranAngolanAnguillanAntiguanArgentineanArmenianArubanAustralianAustrianAzerbaijaniBahamianBahrainiBangladeshiBarbadianBarbudanBasothoBatswanaBelarusianBelgianBelizeanBenineseBermudianBhutaneseBolivianBosnianBrazilianBritishBritish Virgin IslanderBruneianBulgarianBurkinabeBurmeseBurundianCambodianCameroonianCanadianCape VerdeanCentral AfricanChadianChannel IslanderChileanChineseChristmas IslanderChuukeseCocos IslanderColombianComoranCongoleseCook IslanderCosta RicanCroatianCubanCypriotCzechDanishDjiboutianDominicanDutchDutch AntilleanEast TimoreseEcuadoreanEgyptianEnglishEmiratiEquatorial GuineanEritreanEstonianEthiopianFalkland IslanderFaroeseFijianFilipinoFinnishFrenchFrench GuianeseFrench PolynesianGaboneseGambianGeorgianGermanGhanaianGibraltarGreekGreenlandicGrenadianGuadeloupianGuamanianGuatemalanGuineanGuyaneseHaitianHonduranHong Kong (British/Chinese)HungarianI-KiribatiIcelandicIndianIndonesianIranianIraqiIrishIsraeliItalianIvorianJamaicanJapaneseJordanianKazakhstaniKenyanKittian and NevisianKuwaitiKyrgyzLaotianLatvianLebaneseLiberianLibyanLiechtensteinLithuanianLuxembourgerMacedonianMahoranMalagasyMalawianMalaysianMaldivanMalianMalteseManxMarshalleseMartiniquaisMauritanianMauritianMexicanMicronesianMoldovanMonegasqueMongolianMontenegrinMontserratianMoroccanMosothoMotswanaMozambicanNamibianNauruanNAURNepaleseNew ZealanderNicaraguanNigerianNigerienNiueanNi-VanuatuNorfolk IslanderNorth KoreanNorthern IrishNorwegianOmaniPakistaniPalauanPalestinianPanamanianPapua New GuineanParaguayanPeruvianPitcairn IslanderPohnpeianPolishPortuguesePuerto RicanQatariReunioneseRomanianRussianRwandanSahrawianSaint HelenianSaint LucianSaint VincentianSalvadoranSammarineseSamoanSan MarineseSao TomeanSaudi ArabianScottishSenegaleseSerbianSeychelloisSierra LeoneanSingaporeanSlovakianSlovenianSolomon IslanderSomaliSouth AfricanSouth KoreanSpanishSri LankanSudaneseSurinameseSwaziSwedishSwissSyrianTaiwaneseTajikTanzanianThaiTimoreseTobagonianTogoleseTokelauanTonganTrinidadianTrukeseTunisianTurkishTuvaluanUgandanUkrainianUruguayanUzbekistaniVenezuelanVietnameseVirgin IslanderWallis and Futuna IslanderWelshYapeseYemeniteZambianZimbabweanDo not wish to discloseDo you consider yourself to have a disability?(Required)YesNoDo not wish to discloseMany people do not consider themselves to be disabled. However under the Disability Discrimination Act 1995 and the Equality Act 2010, you are protected from discrimination if you have a physical or mental impairment or long term health condition, the effects are expected to last – or have lasted – for a year or longer and have a substantial impact on your ability to carry out day to day activities; or your day to day activities would be limited without medication, treatment or adjustments (for example the use of inhalers, physiotherapy, a hearing or visual aid or insulin). Taking this into account, do you consider yourself to have a disability?About your disabilityVisual impairmentHearing impairmentDisability affecting mobilityOther physical disabilityOther medical condition (for example epilepsy, asthma, diabetes)Emotional/behavioural difficultiesMental health difficultyTemporary disability after illness (for example post-viral) or accidentProfound complex disabilitiesAspergers syndromeOtherNot known/not provided Personal Statement If you are part of a commissioned or local cohort, then you are not required to complete this section. Please feel free to continue by clicking next below.Personal Statement You are applying for a place that is fully funded by NHS England and Improvement as part of the Growing Occupational Health programme. Use the following space to outline why this programme is right for you as an OH leader, how you will use the learning, and what you will give back to OH, and NHS services in return for this fully funded place.Personal Statement Your Personal Statement(Required) Your personal statement is an important part of your application, and should explain why you’re interested in studying on this programme, your relevant experience, and provide a clear argument for why you should have a place. It should be no more than 500 words ± 10%. To support us in reviewing your application for suitability and eligibility, we’d strongly encourage you to make full use of the word count. This programme leads to a NHS Leadership Academy Award in Healthcare Leadership. Your statement should answer the following questions: 1. Why should I have a place on this programme? And why now? 2. What is my relevant professional and leadership experience? 3. Tell us about your current role and the people you lead. 4. Tell us how you plan to meet the requirements for 4 hours of study per week. 5. What support will your line manager/organisation provide for you while you’re on the programme? (500 words) Your Personal Statement – PT(Required) Your personal statement is an important part of your application, and should explain why you’re interested in studying on this programme, your relevant experience, and provide a clear argument for why you should have a place. It should be no more than 1000 words ± 10%. To support us in reviewing your application for suitability and eligibility, we’d strongly encourage you to make full use of the word count. This programme leads to a NHS Leadership Academy Award in Healthcare Leadership. Your statement should answer the following questions: 1. Tell us about your current role and the people/projects/kind of work you lead, demonstrating the complexities and challenges. (250 Words) 2. Tell us what you hope to be able to bring to the programme and how you’ll use your learning to help make a positive impact for both staff and patients/service users. (200 Words) 3. Why have you chosen this programme, why now, and what do you hope to achieve? (200 Words) 4. What are you passionate about, and hoping this programme will help you address, in your work place? (250 Words) 5. What arrangements will you make to create time to study for at least 15-20 hours a month? (100 Words) Keeping in touch We’d like to keep in touch with you on updates about our products, services, promotions, news and events. Please select your preferences to help us keep you up-to-dateWhere did you hear about the programme?NHS Leadership Academy websiteAnother NHS websiteA Journal's website (EG. Nursing Times or Nursing Standard)My organisation's intranetSearch enginePrinted advert in a journal (E.g. Nursing times, Nursing Standard)Email advertWord of mouth (friend or colleague)NHS Leadership Academy Programme GuideLine ManagerStaff BriefingWould you like to receive updates from the Leadership Academy about other programmes on offer?YesNoWould you like to receive updates from the Leadership Academy about other learning opportunities such as bite size learning, mentoring, news and events?YesNoWould you be happy to be contacted by the Academy for research purposes?YesNo(Your views are important to us and help us grow).At the moment updates are delivered via email but we are exploring options to communicate via mobile, would you be happy to receive notifications from us via mobile in the future?YesNo Terms and Conditions1. I confirm that all the information provided in the application form is up to date and accurate. 2. If I am from outside the EU and working in England with a visa; I confirm my UK visa and immigration clearance covers study as well as work. 3. I have full practical, and financial (if organisation funded), support in place from my manager and organisation for me to commit to all aspects of learning during the full duration of the programme. They have agreed to make the necessary workplace arrangements and allow me time away from work in order for me to attend all of the virtual and/or face to face elements. 4. I will attend and partake in all the face-to-face workshops and all the learning activity associated with the programme, including all the assignments regardless of the amount of study leave I am granted. Not attending the programme without agreeing extenuating circumstances with the NHS Leadership Academy could mean that I may lose my place on the programme. 5. I understand that all the elements of the programme are compulsory and attendance is part of the assessment, pass mark, and NHS Leadership Academy accreditation. I understand that the assessment criteria are as follows: a) Completion of all online work through the Virtual Campus b) Mandatory attendance at all three workshops c) Contributions to online discussions d) Submission of a 2,000 word impact written assignment. 6. I understand that the programme is designed around practical learning in the workplace – the most important environment for me to learn and develop as a leader – and that I will not be able to complete the programme without application in my workplace. I understand there is an extenuating circumstances policy in place if I struggle to apply the learning in the workplace, which is provided once the programme commences. 7. I acknowledge that I cannot defer on this programme. 8. The amount of paid or unpaid study leave I receive (in addition to the time away from work for the face to face elements of the programme) will be determined by the relevant policy of or by the management of my employing organisation. 9. I understand that my travel costs and subsistence (other than lunches during the face-to-face days if relevant) are not covered by the fees for the programme and my employing organisation’s expenses policy will apply. 10. I understand that if I move jobs during the programme: a) This does not automatically constitute extenuating circumstances for withdrawal from the programme; and b) I will make my new employer and line manager aware before I accept the job offer that I am committed to complete the programme and will require their support to do so. 11. If I am self-funding, if, having accepted a place, I either fail to start or fail to complete the programme for any reason whatsoever (other than for a reason that the NHS Leadership Academy in its absolute discretion determines is an extenuating circumstance), I will remain liable to still pay the programme fee and the fee will not be refunded. Please check the box below to accept our Terms and Conditions(Required) I agree to the Terms and Conditions SummaryPlease check your details and, if correct, submit this form. {all_fields:nohidden,noadmin} Problems? For technical support email support@leadershipacademy.nhs.uk Otherwise email seacoleprogramme@leadershipacademy.nhs.uk Please note, Internet Explorer is not a supported browser for this Application site.