Kent and Medway Public HealthChampions

Please fill in this form as confirmation of your attendance and agreement to fulfilling the requirements of the Public Health Practice Champions Programme- Cohort 3:2016/17

To apply for a place on the programme, you MUST be able to attend ALL of the following dates (Taught Days are all on Fridays)
Module 1
Time / 09:30 am to 17:30 pm
Venue / Canterbury Christchurch University Campus, Rowan Williams Court, 30 Pembroke Court, Chatham Maritime, Kent ME4 4UF.
Dates / 1, 8 and 15 July 2016 (3 days)
9,, 16 and 23September 2016 (3 days)
Module 2
Time / 09:30 am to 17:30 pm
Venue / Canterbury Christchurch University Campus, Rowan Williams Court, 30 Pembroke Court, Chatham Maritime, Kent ME4 4UF.
Dates / 9 and 16 December 2016 (2 days)
13 and 20 January 2017 (2 days)
Total Attendance Required / 10 Taught Days
5 Half Day Action Learning Sets
Celebration Day on 21 July 2017

Please note: You must be an employee or voluntary worker of an organisation in Kent and/or Medway

  1. Applicant Details

Title: / Name:
Job Title:
Department:
Organisation:
Work Address:
Work Email:
Home Email:
Work and Home Telephone:
Work Mobile:
Accessibility or Dietary Requirements
  1. Details of your line manager

Name:
Job Title:
Work Address:
Work email Address:
Work Telephone:
Mobile:
  1. Where did you find out about this programme?
  1. Have you attended or will you be attending an information session?
  1. Are you aware that as part of the programme you MUST attend the following:

Please Tick Attending
10 Taught Days (as per dates above)
5 Half Day Action Learning Sets (dates to be set by ALS)
Celebration Event (on 21 July 2017)
  1. Are you aware that you as part of the programme you will be:

Please Tick Attending
Drafting a 4000 word Neighbourhood Study
Drafting a 4000 word Case Study
Preparing a group presentation for Celebration Event (on 21 July 2017)
  1. Do you know of anyone (other than your line manager) that could act as your mentor to support you through the programme? This person should have some Public Health knowledge. There will be a separate training session organised for them.

If yes please give their name. If not we will match you with a mentor at a later date.

Name:
Title:
Contact Details
  1. Why do you want to become a Public Health Champion?
  1. How will you actively champion and encourage colleagues and managers to be aware of their public health responsibilities?
  1. How committed and enthusiastic are you about health promotion and public health?
  1. Acting as a Public Health Champion (PHC) in the future

As a Public Health Champion I agree to take the lead for:

  • Integrating learning into my everyday work
  • Sharing my learning from the programme with the team/organisation
  • Being an advocate for the health inequalities and health improvement agenda
  • Updating my team and partners
  • Promoting partnership working
  • Disseminating public health information e.g.magazine, CPD programme
  • Being a mentor, if possible, for future champions
  • Attending annual Public HealthChampion Network meetings and other relevant CPD events
  • Informing the Lead Officer for PHC of any public health related development needs of team/organisation.
  • Promoting the programme to teams/organisations.
  1. Applicant Declaration

  • As the applicant I commit to attending the 10 taught days, learning sets, mentor sessions and the celebration day on 21 July 2017.
  • I also commit to undertaking 2 x 4000 work assignments for accreditation. I understand that I will also be required to produce information, on any projects arising and prepare a presentation for the celebration event.
  • I understand that a charge of £250 will be made to my organisation should I withdraw, once the taught days have commenced, without good reason. (The cost per place is approx £1,200).

Signature:…………………………………………………… Date: ……………………………

(Applicant)

  1. Line Manager Declaration

  • As the Line Manager, I confirm that the organisation supports this application and will ensure that priority will be given to attendance at taught days, learning sets, mentor sessions and the celebration day.
  • As the Line Manager I will ensure that there will be opportunities for putting learning into practice and that some work time will be given to complete the accreditation. The applicant will also be required to contribute some of their own time towards completing the accreditation.
  • I understand that a charge of £250 will be made to the organisationshould the practitioner withdraw, once the taught days have commenced, without good reason. (The cost per place is approx £1,200).

Signature: ……………………………………………………. Date: ……………………………

(Line Manager)

Forms must be physically signed by Applicant and Line Manager – electronically scanned signatures are accepted and preferred where available.

Please send your completed application form to arrive no later than
27 April 2016 to:
Email:
Post: Tiana Stannard, Kent Public Health Department, Kent County Council, Room 3.45, Sessions House, County Hall, County Rd, Maidstone, Kent, ME14 1XQ.

Applications that arrive after this date will not be considered.Applications will be shortlisted according to specific criteria due to a limited number of spaces.

You will be notified by email if you have been successful or not. This email will be sent no later than 29 April 2016.

If you have any further questions please telephone on: 03000 416722