Future leaders in Anaesthesia Leadership Development Programme delivered by the Association of Anaesthetists of Great Britain and Ireland in partnership with Bayes Business School

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Page 1

Application Form

Places are funded by Association and limited to 21. Applications will be assessed based on merit, commitment to leadership in anaesthesia and potential impact..

PERSONAL DETAILS

Title

First name

Last name

Home address

Postcode

Mobile number

Special dietary requirements

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PROFESSIONAL INFORMATION

Current job title/role

NHS Trust/Employer

Address line 1

Address line 2

Town/City

County

Postcode

Association membership number

If you are not sure, please write 'Unsure'.

GMC number

Years of experience in anaesthesia

Are you currently in a formal leadership role?

YesNo

If yes, please specify:

Page 3

COMPELLING STATEMENT (max. 500 words)

Why should you be selected for this Leadership Development Programme?

SUPPORTING INFORMATION

Have you undertaken any previous leadership training or development?

YesNo

If yes, please provide brief details

What do you hope to achieve as a result of attending this programme?

How do you intend to share or disseminate what you learn

Who will support your application? Select the appropriate role:

Clinical DirectorEducational SupervisorRCoA College TutorTraining Programme Director

Page 4

EQUAL OPPORTUNITIES MONITORING (OPTIONAL)

Gender

Ethnicity

Disability or accessibility needs we should be aware of:

APPLICANT DECLARATION

I confirm that the information provided is accurate to the best of my knowledge.

I understand that places are limited and that submitting this form does not guarantee selection.

I agree to commit fully to the programme if selected.

Type applicant's name (serves as signature)

Date

Page 5

CONTACT PREFERENCES

In processing your personal data to respond to and follow up on your application, we will do this securely and only use the information for your chosen purposes. We will never sell, rent or lease it to 3rd parties. Please read our full privacy notice here. To talk to us about how we use your information or report a concern please email dataprotection@city.ac.uk

Please complete the details below to confirm your consent for us to contact you

By selecting this option, you consent to join our mailing list. We’ll keep you updated with relevant news, events and information about your chosen programme to support your application and decision-making. You can unsubscribe at any time.By selecting this option, you are choosing to remain unsubscribed from our mailing list.

TERMS AND CONDITIONS

Please ensure you have read the following programme terms and conditions:

• Attendance at all 12 in-person programme days is mandatory. In the absence of extenuating circumstances, any missed sessions may result in the Association requesting a financial contribution towards the cost of the place.

• Applicants must be supported by their Training Programme Director/ Educational Supervisor and/or Clinical Director. We have written to all Clinical Directors, College Tutors, SAS Educational Supervisors and Training Programme Directors to inform them of the programme.

• This programme is an exclusive benefit for members of the Association. Only current members are eligible to apply. Successful applicants must maintain their membership throughout the duration of the programme. Should membership lapse, the participants may become liable for the full cost of the programme.

Do you agree to the above terms and conditions?

By ticking this box, I confirm that I have read and agree to the terms and conditions.

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