Registration Event Registration Step 1 of 4 25% We need to collect a few details about you to complete your registration. Please complete the fields below.This field is hidden when viewing the formEvent ID OptionalAcademy ID OptionalIf you have an Academy ID, please enter it here. If you don’t or cannot remember it, please leave this field blankYour Name First Last Email RegionPlease state what Region you are working for/in:— Please Select —East of EnglandMidlandsLondonNorth East & YorkshireNorth WestSouth EastSouth WestOtherPlease specify OptionalIf you selected “Other” for your region, please specify more detail Next, we need a little information about your work. This is so we can report accurately on the impact our events and programmes are having across the system, and ensure we are providing the correct content for you.Job Role / Title Staff GroupAdditional Clinical ServicesAdditional Professional Scientific & TechnicalAdministrative & ClericalAllied Health ProfessionalsEstates & AncillaryHealthcare ScientistsMedical & DentalNursing & Midwifery RegisteredStudent Job Title Role typeWould you describe your role as: Clinical – I provide clinical care Non-clinical – I do not provide any clinical care Role Type – Other OptionalIf you selected Other, please specifyWork SectorDo you work, or is your primary role, in the following area of care Primary Care Secondary Care Voluntary, community and social enterprise (VCSE) sector care Social Care Local Government I do not wish to disclose Unknown Other Work Sector – Other OptionalIf you selected Other, please specifyPatient FacingDo you have face-to-face contact with patients / service users are part of your day job— Please Select —Yes, frequentlyYes, occassionallyNoPay BandFor NHS and Social Care staff only – Please select your Agenda for Change band— Please Select —OtherAfC Band 1AfC Band 2AfC Band 3AfC Band 4AfC Band 5AfC Band 6AfC Band 7AfC Band 8aAfC Band 8bAfC Band 8cAfC Band 8dAfC Band 9VSM / ESMConsultantPay – Other Optional£0 – £19,999 per year£20,000 – £29,999 per year£30,000 – £39,999 per year£40,000 – £49,999 per year£50,000 – £59,999 per year£60,000 – £69,999 per year£70,000 – £79,999 per year£80,000 – £89,999 per year£90,000 – £99,999 per year£100,000 or above per yearDo you work Full Time Optional— Please Select —Full TimePart TimeOrganisationPlease let us know the organisation you work for. CountryEnglandNorthern IrelandScotlandWalesOutside UK Organisation Type Organisation Name Integrated Care System OptionalPlease let us know the Integrated Care System your work is covered by. N.B. This will be populated dynamically when we have the smart selection of organisation above, so have left as text field for testing purposes Your motivationThinking about your motivations, please identify one objective which you hope to achieve in attending this event.Your line manager I confirm that I have my line manager’s support to attend this eventLine Manager email OptionalPlease provide your line manager’s email address Line manager contactFor the purposes of longer term evaluation for some of our programmes, would you be prepared for us to make contact with your line manager? We will always contact you at the same time. I am happy for contact to be made with my line manager for evaluation of our programmes. OptionalRecording This session may be recorded. Please confirm that you are in agreement with thisCancellation PolicyAttendance and Cancellation Policy Your commitment to attendance is crucial to the success and outcome of our events, as well as your continued personal development. Spaces are limited and non-attendance prevents others from benefiting from the opportunity. If you are no longer able to attend, please email CONTACT EMAIL ADDRESS as soon as possible so that we can offer the space to another applicant. Where a programme requires full attendance over a series of workshops, attendance at all elements of the programme is expected. Places cancelled at short notice can occasionally lead to events being cancelled or postponed, as running events with fewer participants can impact the learning and overall success. However, we understand that cancelling at short notice is sometimes unavoidable. Please note cancellations with less than 1 working weeks’ notice may be reported to the sponsoring organisation. We reserve the right to cancel or postpone an event should unexpected circumstances occur. Should an event need to be cancelled we will not be held responsible for any travel or accommodation that has been pre-booked by the attendee. We are committed to looking at ways we can improve and develop our Leadership Development offers. Your feedback supports us and providers to ensure we are delivering the right interventions in the right way. As such, we would be grateful for your participation in any post-event follow-up & evaluation. Privacy Notice The NHS Leadership Academy is part of NHS England. NHS England respects your privacy and is committed to protecting your personal data. This privacy notice will inform you as to how we look after your personal data and tell you about your privacy rights and how the law protects you. Your details and offer participation may be shared with your organisation or Integrated Care System (ICS), to support the update of Leadership & Development records. Information is shared in line with relevant data protection legislation. For full details of how we manage your information please see our privacy notice here NHS England » NHS England’s privacy notice (https://www.england.nhs.uk/contact-us/privacy-notice) This privacy statement covers this NHS Leadership Academy website. It does not cover all sites that can be linked to and from this site. You should always be aware when you are moving to another site and read the privacy statement on that respective site. Please confirm that you have read and agreed to our Attendance and Cancellation PolicyFollow UpYour booking may not be accepted without this I am happy to participate in the event follow up and evaluation OptionalHow did you hear about this development opportunity Twitter Newsletter Email campaign Word of mouth Leadership Academy / Regional LLL website Other How did you hear about this – Other OptionalIf you selected Other, please specifyNewsletterI would like to receive the newsletter with information about current programmes and courses offered by my regional Leadership Academy Yes No I already receive the newsletter ContactWould you be happy for us to contact you for further information? Yes No Graduate SchemeAre you Alumni of the NHS Graduate Management Training Scheme?— Please Select —YesNoGMTS intake year OptionalWhat was your intake year for the NHS Graduate Management Scheme?GMTS Specialism OptionalWhat was your specialism in the NHS Graduate Management Scheme?— Please Select —General ManagementFinanceHuman ResourcesHealth AnalyticsHealth InformaticsPolicy and Strategy Management We hold the principles of equality and inclusion at the heart of everything we do and all that we stand for. Each Regional Leadership Academy is held to account for its inclusion practice through a review of anonymised statistics based on this data. Your equality and diversity data is not used to determine the status of your registration. This data is stored securely in compliance with the General Data Protection Regulation (GDPR) 2016. In each question you have the option to select “Do not wish to share” or leave the field blank should you prefer to do so.Date of Birth OptionalWe use this to ensure that we are offering opportunities to all age groups , and that the mix of attendees to our offers matches the blend of staff within our workforce. DD slash MM slash YYYY Marital Status— Please Select —OtherSingleMarried / Civil PartnerDivorced / person whose civil partnership has been dissolvedWidowed / surviving civil partnerSeparatedPrefer not to shareMarital status – Other OptionalIf you selected Other, please specifySexual OrientationWhich of the following best describes your sexual orientation?— Please Select —OtherHeterosexual or StraightLesbianGayBisexualAsexualOther sexual orientation not listedUndecidedPrefer not to shareSexual orientation – Other OptionalIf you selected Other, please specifyGenderWhich of the following best describes your gender?— Please Select —FemaleMaleNon BinaryPrefer not to shareGender – Other OptionalIf you selected Other, please specifyIs your gender identity the same as assigned at birth? Yes Optional No Optional Prefer not to share Optional NationalityWhich of the following best describes your nationality?— Please Select —AfghanAlbanianAlgerianAmericanAmerican SamoanAndorranAngolanAnguillanAntiguanArgentineanArmenianArubanAustralianAustrianAzerbaijaniBahamianBahrainiBangladeshiBarbadianBarbudanBasothoBatswanaBelarusianBelgianBelizeanBenineseBermudianBhutaneseBolivianBosnianBrazilianBritishBritish Virgin IslanderBruneianBulgarianBurkinabeBurmeseBurundianCambodianCameroonianCanadianCape VerdeanCentral AfricanChadianChannel IslanderChileanChineseChristmas IslanderChuukeseCocos IslanderColombianComoranCongoleseCook IslanderCosta RicanCroatianCubanCypriotCzechDanishDjiboutianDominicanDutchDutch AntilleanEast TimoreseEcuadoreanEgyptianEnglishEmiratiEquatorial GuineanEritreanEstonianEthiopianFalkland IslanderFaroeseFijianFilipinoFinnishFrenchFrench GuianeseFrench PolynesianGaboneseGambianGeorgianGermanGhanaianGibraltarGreekGreenlandicGrenadianGuadeloupianGuamanianGuatemalanGuineanGuyaneseHaitianHonduranHong Kong (British/Chinese)HungarianI-KiribatiIcelandicIndianIndonesianIranianIraqiIrishIsraeliItalianIvorianJamaicanJapaneseJordanianKazakhstaniKenyanKittian and NevisianKuwaitiKyrgyzLaotianLatvianLebaneseLiberianLibyanLiechtensteinLithuanianLuxembourgerMacedonianMahoranMalagasyMalawianMalaysianMaldivanMalianMalteseManxMarshalleseMartiniquaisMauritanianMauritianMexicanMicronesianMoldovanMonegasqueMongolianMontenegrinMontserratianMoroccanMosothoMotswanaMozambicanNamibianNauruanNAURNepaleseNew ZealanderNicaraguanNigerianNigerienNiueanNi-VanuatuNorfolk IslanderNorth KoreanNorthern IrishNorwegianOmaniPakistaniPalauanPalestinianPanamanianPapua New GuineanParaguayanPeruvianPitcairn IslanderPohnpeianPolishPortuguesePuerto RicanQatariReunioneseRomanianRussianRwandanSahrawianSaint HelenianSaint LucianSaint VincentianSalvadoranSammarineseSamoanSan MarineseSao TomeanSaudi ArabianScottishSenegaleseSerbianSeychelloisSierra LeoneanSingaporeanSlovakianSlovenianSolomon IslanderSomaliSouth AfricanSouth KoreanSpanishSri LankanSudaneseSurinameseSwaziSwedishSwissSyrianTaiwaneseTajikTanzanianThaiTimoreseTobagonianTogoleseTokelauanTonganTrinidadianTrukeseTunisianTurkishTuvaluanUgandanUkrainianUruguayanUzbekistaniVenezuelanVietnameseVirgin IslanderWallis and Futuna IslanderWelshYapeseYemeniteZambianZimbabweanPrefer not to shareEthnicityWhich of the following best describes your ethnic background?— Please Select —White – BritishWhite – IrishWhite – Any other White backgroundMixed – White and Black CaribbeanMixed – White and Black AfricanMixed – White and AsianMixed – Any other Mixed backgroundAsian or Asian British – IndianAsian or Asian British – PakistaniAsian or Asian British – BangladeshiAsian or Asian British – Any other Asian backgroundBlack or Black British – CaribbeanBlack or Black British – AfricanBlack or Black British – Any other Black backgroundOther ethnic groups – ChineseOther ethnic groups – Any other ethnic groupDo not wish to shareReligionWhich of the following best describes your religion or belief system?— Please Select —AtheismBuddhismChristianityHinduismIslamJainismJudaismSikhismNot religiousOtherPrefer not to shareDisabilityMany people do not consider themselves to be disabled. However under the Disability Discrimination Act 1995 and the Equality Act 2010, you are protected from discrimination if you have a physical or mental impairment or long term health condition, the effects are expected to last – or have lasted – for a year or longer and have a substantial impact on your ability to carry out day to day activities; or your day to day activities would be limited without medication, treatment or adjustments (for example the use of inhalers, physiotherapy, a hearing or visual aid or insulin). Taking this into account, do you consider yourself to have a disability?— Please Select —YesNoPrefer not to shareAbout your disability Visual impairment Optional Hearing impairment Optional Disability affecting mobility Optional Other physical disability Optional Other medical condition (for example epilepsy, asthma, diabetes) Optional Emotional/behavioural difficulties Optional Mental health difficulty Optional Temporary disability after illness (for example post-viral) or accident Optional Profound complex disabilities Optional Aspergers syndrome Optional Other Optional Not known/not provided Optional