Home Student Leadership Ambassadors Scheme application form 2023 We would recommended you click ‘Save and Continue Later’ button to avoid your application being lost as you proceed through the questions. 1Privacy Agreement2About you3Equality and Diversity4Keeping in Touch5Terms and Conditions6Summary Application-IDThis field is hidden when viewing the formSubmission Date DD dash MM dash YYYY Privacy Agreement Any information you provide in completing this application will be stored and processed in accordance with our Data Privacy Policy which you are required to read and accept before completing your application. By proceeding with this application, you agree that The NHS Leadership Academy may contact you if you have partially completed your application to offer guidance and support with finishing your application. This is a separate agreement to the marketing preferences selected further in this application.Please check the box below to accept the above agreement and our Data Privacy Policy(Required) I confirm I have read and accept the Academy’s Data Privacy Policy and above agreement Please note this form is closed and applications will not be countedAbout youName(Required) First Last Preferred NameYour University:(Required)Your University Email(Required) Your primary email addressPreferred contact number(Required)Your main contact number with international dialling code and extension if necessaryDate of Birth DD dash MM dash YYYY Please enter your 10-digit Academy ID(Required)If you already have an Academy ID, please log on to our new Academy Profile system using your existing log in details to ensure your account is transferred to our new system. If you need help remembering your existing Academy ID, please use the Reset password feature on the Profile system. If you do not have an Academy ID, please register on our Academy Profile system to create one. Home address Street Address City ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Region(Required)East of EnglandLondonMidlandsNorth East and YorkshireNorth WestSouth EastSouth WestWalesScotlandNorthern IrelandNon-UK Equality & Diversity We hold the principles of equality and inclusion at the heart of everything we do and all that we stand for. Each programme 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 success of your application. This data is stored securely in compliance with the General Data Protection Regulation (GDPR) 2016.Which of the following best describes your gender?(Required)FemaleMaleUnknown GenderDo not wish to discloseAre you now or have you ever defined yourself as Trans?(Required)YesNoDo not wish to discloseWhich of the following best describes your sexual orientation?(Required)Heterosexual or StraightLesbianGayBisexualAsexualOther sexual orientation not listedUndecidedDo not wish to discloseWhich of the following best describes your ethnic background?(Required)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 discloseWhich of the following best describes your religion or belief system?(Required)AtheismBuddhismChristianityHinduismIslamJainismJudaismSikhismNot religiousOtherDo not wish to discloseWhich of the following best describes your nationality?(Required)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 IslanderWelshYapeseYemeniteZambianZimbabweanDo not wish to discloseDo you consider yourself to have a disability?(Required)YesNoDo not wish to discloseMany 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?About your disabilityVisual impairmentHearing impairmentDisability affecting mobilityOther physical disabilityOther medical condition (for example epilepsy, asthma, diabetes)Emotional/behavioural difficultiesMental health difficultyTemporary disability after illness (for example post-viral) or accidentProfound complex disabilitiesAspergers syndromeOtherNot known/not provided Keeping in touch We’d like to keep in touch with you on updates about our products, services, promotions, news and events. Please select your preferences to help us keep you up-to-dateWhere did you hear about the programme?NHS Leadership Academy websiteAnother NHS websiteA Journal's website (EG. Nursing Times or Nursing Standard)My organisation's intranetSearch enginePrinted advert in a journal (E.g. Nursing times, Nursing Standard)Email advertWord of mouth (friend or colleague)NHS Leadership Academy Programme GuideLine ManagerStaff BriefingWould you like to receive updates from the Leadership Academy about other programmes on offer?YesNoWould you like to receive updates from the Leadership Academy about other learning opportunities such as bite size learning, mentoring, news and events?YesNoWould you be happy to be contacted by the Academy for research purposes?YesNo(Your views are important to us and help us grow).At the moment updates are delivered via email but we are exploring options to communicate via mobile, would you be happy to receive notifications from us via mobile in the future?YesNo Terms and ConditionsBy applying for this programme I have both the agreement of my line manager, organisation and secured the time away for my chosen cohort(s) Please check the box below to accept our Terms and Conditions(Required) I agree to the Terms and Conditions SummaryPlease check your details and, if correct, submit this form. {all_fields:value,nohidden,noadmin}