Chairs of Integrated Care System (ICS) Shared Decision Making Councils Application Form

Programme

PLEASE NOTE: This form requires you to upload images and documents and many firewalls and NHS computers and laptops will not allow this. When completing this form, it is advised that you use your own personal computer and home wifi when completing this form, when possible. Thank you.

Programme *

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Your Details

Title *

If there is not a suitable option please select "Other".

If "Other" please enter your Title *

Name *

First

Last

Previous Last Name

If you are known by a previous last name please enter your previous last name here.

Email Address *

Confirm Email

Alternative Email Address *

Confirm Email

If you don't have an alternative email address just enter your email address again.

Home Phone

Mobile *

Date of Birth *

Twitter Handle

LinkedIn Profile

Home Address *

Street Address

Town/City

County/State

Postal/Zip Code

Home Country *

If there is not a suitable option please select "Other".

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Job Details

Full Job Title *

Profession *

If there is not a suitable option please select "Other".

If "Other" please enter your Profession *

Professional Registration Number *

Year you qualified *

Registration Document *

Click or drag a file to this area to upload.

Please note: Files must be under 10MB.

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Qualifications

Please enter up to 6 qualifications.

Qualification 1: Name *

Qualification 1: Institution Name *

Qualification 1: Major Field of Study *

Qualification 1: Month Commenced *

Qualification 1: Year Commenced *

Qualification 1: Month Completed *

Qualification 1: Year Completed *

Would you like to add a second qualification? *

Qualification 2: Name *

Qualification 2: Institution Name *

Qualification 2: Major Field of Study *

Qualification 2: Month Commenced *

Qualification 2: Year Commenced *

Qualification 2: Month Completed *

Qualification 2: Year Completed *

Would you like to add a third qualification? *

Qualification 3: Name *

Qualification 3: Institution Name *

Qualification 3: Major Field of Study *

Qualification 3: Month Commenced *

Qualification 3: Year Commenced *

Qualification 3: Month Completed *

Qualification 3: Year Completed *

Would you like to add a fourth qualification? *

Qualification 4: Name *

Qualification 4: Institution Name *

Qualification 4: Major Field of Study *

Qualification 4: Month Commenced *

Qualification 4: Year Commenced *

Qualification 4: Month Completed *

Qualification 4: Year Completed *

Would you like to add a fifth qualification? *

Qualification 5: Name *

Qualification 5: Institution Name *

Qualification 5: Major Field of Study *

Qualification 5: Month Commenced *

Qualification 5: Year Commenced *

Qualification 5: Month Completed *

Qualification 5: Year Completed *

Would you like to add a sixth qualification? *

Qualification 6: Name *

Please enter the full name of your organisation and try to avoid using any acronyms where possible.

Qualification 6: Institution Name *

Qualification 6: Major Field of Study *

Qualification 6: Month Commenced *

Qualification 6: Year Commenced *

Qualification 6: Month Completed *

Qualification 6: Year Completed *

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Employing Organisation Details

Employing Organisation *

Please enter the full name of your organisation and try to avoid using any acronyms where possible.

Work Address *

Street Address

Town/City

County/State

Postal/Zip Code

Work Location *

If there is not a suitable option please select "Not Applicable".

Work Country *

If there is not a suitable option please select "Other".

Work Phone *

Work Mobile *

Work Email Address *

Confirm Email

If you don't have a work email address just enter your email address again

Biography

In order to stimulate the networking process for participants, we ask that you send us a short biography.

Biography *

Please note: Biographies may be edited for consistency and style. Include information on your current and previous roles and interests. Write in the third person. Clarify any abbreviations used.

Upload Headshot *

Click or drag a file to this area to upload.

Headshot instructions: head and shoulders only. This photo will be used for your records and will accompany your biography where appropriate. Please note: Files must be under 10MB.

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Application

Please tell us about the service or organisation you work for or run *

Please include details of your service or organisation type and setting.

Please describe your role *

Please describe how you connect to other colleagues and organisations outside of your own service, including membership of any networks or forums, and why this is important *

Why do you feel it is important that the nursing profession and adult social care are represented in local decision making? *

Which ICB do you work within? *

Please can we put you in touch with your Skills for Care locality manager? *

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Senior Sponsor

We require information from a senior sponsor.

Please download the senior sponsor form which is to be filled in by a senior person from your organisation that is supporting your application.

Please rename your senior sponsor form prior to upload to include your professional registration number and name e.g. 'Senior Sponsor form - John Smith 12345'.

Please note forms are to be filled out electronically. Hand-written submissions will not be accepted.

Senior Sponsor Name *

First

Last

Senior Sponsor Email Address *

Confirm Email

Work Phone/Mobile *

Senior Sponsor Form *

Click or drag a file to this area to upload.

Please note: Files must be under 10MB.

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Diversity

We are keen to develop diversity in all areas. By completing this section you are helping us to build a picture of those attending our sessions. The information collected is stored in our database and not shared with any third parties.

Age Group

Gender *

If there is not a suitable option please select "Prefer to Self-describe".

If "Prefer to Self-describe" please enter your Gender *

Is your gender identity the same as the sex you were registered at birth? *

Yes
No
Prefer Not to Say

Ethnicity *

If there is not a suitable option please select "Other" or "Unknown".

If "Other" please enter your Ethnicity *

Nationality *

If there is not a suitable option please select "Other".

If "Other" please enter your Nationality *

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Special Requirements

Do you have any disability or accessibility needs or requirements? *

If "Yes" please enter your disability or accessibility needs *

Do you consider yourself to have a specific learning difficulty? *

If "Yes", please select a learning difficulty *

Do you have any special dietary requirements? *

If "Yes" please enter your special dietary requirements *

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Programme Administration

How did you hear about us? *

If "Other" please enter how you heard about us *

Have you previously applied for an FNF Scholarship? *

If "Yes" were you successful? *

Have you previously been involved in a FNF Leadership programme? *

If "Yes" please enter the leadership programme name *

Have you previously completed a professional scholarship or fellowship? *

If "Yes" please enter details of the professional scholarship or fellowship *

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Terms and Conditions

We would like to keep you informed about the vital work we do at the Foundation including events, marketing, fundraising and newsletters and we would like you to engage with other scholars.

We will never sell your data and we promise to keep your details safe and secure. You can change your mind at any time by emailing [email protected].

'We’ includes the Florence Nightingale Foundation only.

Would you like to receive communications from Florence Nightingale Foundation? *

YES, I would like to receive communications from Florence Nightingale Foundation
NO, I do not wish to receive communications from Florence Nightingale Foundation

Please tick the boxes below to tell us all the ways you would prefer to hear from us:

I would like to receive communications by EMAIL

I would like to receive communications by PHONE

I would like to receive communications by PHONE

I would like to receive communications by POST

I would like to receive communications by POST

Data Consent *

I AGREE for my details and data to be stored and maintained on Salesforce, a secure platform used by the Florence Nightingale Foundation

GDPR: means (i) unless and until the GDPR is no longer directly applicable in the UK, the General Data Protection Regulation, Regulation 2016/679/EU, and any national implementing laws, regulations and secondary legislation, as amended or updated from time to time, in the UK and then (ii) any successor legislation to the GDPR or the Data Protection Act 1998.

Please read our privacy policy here on how we manage our data.

Terms and Conditions *

I AGREE to all the terms and conditions and I consent to my data being shared with carefully selected parties as part of the application process

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 I will commit to attend all programme days.

FlorenceNightingale Foundation