ACCL Application Form

Name

First

Last

Qualifications

Job Title

Professional Group

If Other, please specify

Region

Organisation

Contact Tel. No.

Contact Email

Short Biography (100 words only)

As a leader within your system, what objectives do you hope to achieve over the next three years

What are your expectations of the Advanced Clinical & Care Leaders Programme of how it can assist you to achieve these objectives

0 of 100 max words

Any previous leadership development & courses attended

In no more than 100 words, please tell us why you would like to attend the NHS CLN Advanced Clinical & Care Leaders Programme (ACCL)

0 of 100 max words

Please share any experience of coaching which you have received in the past or present

0 of 100 max words

Purchase Order Number

Invoice F.A.O

Invoicing Organisation Name

Invoicing Organisation Address

Please attach the Purchase Order here

Maximum file size: 52.43MB

By selecting this box you are agreeing to attend the full programme and paying the cost of the programme in advance of day 1

I agree

By selecting this box and completing the contact details you agree that you have received written approval from your line manager

I agree

Line Manager Name

First

Last

Line Manager Email

If you are human, leave this field blank.