Dates
Day 1: Tue 14th November 2017
Day 2: Wed 13th December 2017 / Venue
Norton Park, Winchester
Norton Park, Winchester
Please complete the following information and email this form to by 14th September 2017. Applications will be reviewed and decisions communicated as soon as soon as possible after this date.
The following criteria will be used for selection:
·  alignment of personal objectives for the programme with the programme content
·  demonstration of commitment to personal leadership development
·  acceptance of the cancellation policy
·  support from your employer
By attending this programme you will be committing to:
·  participate in the NHS TVWLA Mentoring Scheme and Register.
·  mentoring a minimum of two mentees per annum, meeting them every 6-8 weeks. (These should not be your direct reports and at least one of these needs to be outside your professional sector).
Selection will be carried out by programme faculty. Application does not guarantee a place.
Please answer all the questions below - feel free to expand the form, as required, to suit your answers. Please note that we will share application forms, in line with information governance guidelines, with the programme provider to allow them to understand participant thinking and adapt the programme accordingly if required. If you are successful and accept your place on this programme we will share your email address with other participants on the programme, and with other cohorts of the programme if this is required i.e. to build a network.
If successful, final joining instructions will be sent 2 weeks prior to the first workshop.

Personal Details (please complete all fields)

Name
Role/title
Your employing organisation
Email Address
Phone Numbers (please provide your Office and Mobile phone numbers) / Office:
Mobile:
Do you have any special requirements?
If you require any special requirements, i.e. access, dietary.
Do you have the full support of your HD Director and Line Manager to attend this programme?
Line Managers Name:
Leadership Leads Name:
Leadership Leads Signature (required for successful application) / YES
NO
………………………………………
Line manager’s statement in support of this application:
Leadership Development Leads statement in support of this application:
Invoicing Address / Details for programme fees
For late cancellations or non-attendance - please see booking conditions below
Biographical Information
Length of time in your current role:
Outline recent actions you have taken to support the development of others:
Outline what (of any) mentoring you have undertaken in the last 2 years and the outcomes achieved:
Outline how this programme will develop your capability to mentor as part of your current role:
Please can you outline below an area of development that requires your leadership and which you will be able to develop during the 5 days of the programme, using the tools and techniques that you will learn.
What are your personal objectives in attending this programme? Please give a considered response to this question.
How will you and your line manager know if you have achieved your objectives?
Why should we offer you a place on this programme?
IMPORTANT Booking Details & Conditions
This programme is funded by the Thames Valley and Wessex Leadership Academy. In order to successfully complete the programme you are expected to attend both days. It is not possible to attend part of the programme.
If you are accepted on this programme you will need to commit to the following:
Ø  that you attend BOTH sessions (unless previously agreed with TVWLA or the facilitator).
Ø  that you will complete and return any evaluation questionnaires required at the end of the programme and also participate in any post-programme follow up, especially to evaluate long term impact.
In order to demonstrate best value to patients and taxpayers, we need to ensure maximum attendance on leadership development programmes and events. Failure to attend without a justifiable reason* will result in NHS TVWLA reporting this absence, and related costs, to your HR Director/Accountable Officer. TVWLA operates a membership model so your employing organisation is making a financial contribution to this leadership programme and will expect full attendance by employees who take up places.
*workload pressure is not considered a justifiable reason.
If you secure and confirm a place on this programme and fail to attend any element, your employer/organisation will be charged £300 for the total cost of your place.
Your application will be reviewed by programme faculty.
I have read and understand the booking conditions
We cannot proceed with your application unless this box is ticked
Thank you for completing this form, please return to:

Please hold all the programme dates in your diary.