Stepping Up – Mentoring 1Privacy Agreement2Programme Information3Programme Terms4Contact Details5Current Job Role6Equality & Diversity7Dietary Requirements8Candidate Profile9Candidate Profile Continued10Summary 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.Please check the box below to accept our Data Privacy Policy* I confirm I have read and accept the Academy’s Data Privacy Policy Programme Information Thank you for registering your interest for the Stepping Up opportunity for mentoring with members of the Women’s Leaders’ Network. I am pleased to confirm that you have been allocated a place on the pilot cohort. The first key action is to confirm your attendance at the kickoff workshop detailed below. This will explore the nature and potential benefits of mentoring, help you prepare so that you can make the most of your engagement with your mentor, and explore how you might approach the mentoring relationship. This will take place as follows: Thursday 05 December 2019, 10:30 – 17:30 Friday 06 December 2019, 09:00 – 15:30 Venue: NHS Leadership Academy 3, Embankment Sovereign Street Leeds LS1 4BJ It is essential that everybody taking part in the programme has the same briefing and understanding of the goals, and this will include some preparatory exercises. Mentees must acknowledge that this is a process of continuous holistic learning which involves ongoing experiential development. In the context of mentoring this depends on relationships which form a good level of trust that in turn allows people to go further in their development than they might otherwise achieve. For these reasons it will not be possible to join this initial cohort if you are unable to attend the two-day workshop. To support this, the Academy will be able to arrange overnight accommodation for the night of 05 December, and rail travel (or reimburse mileage expenses). Confirmation Terms*I wish to confirm my interest in attending the mentoring workshop on 05 & 06 December and understand that: 1. My participation in this workshop is under the terms and conditions of the Stepping Up programme, which I have previously accepted. 2. I will be required to commit to and meet an ongoing programme of engagement and reflective practice to be agreed between myself and my mentor. 3. If I do not attend I will not be able to join the pilot mentoring cohort. I wish to confirm my attendance Accommodation*I require overnight accommodation on the evening of 5 December.YesNoRail Travel*I require rail travel to/from LeedsYesNoTravel Location*Where do you require rail travel to/from Contact DetailsName* First Last Email*Your primary email address Secondary EmailYour secondary email address Post Code*Your home post code Phone*Your main telephone number with international dialing code and extension if necessary Job Role Please enter the details of your current main job role.Organisation* CountryEnglandNorthern IrelandScotlandWalesOutside UK Organisation Type Organisation Name Country*Please select your countryAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweOrganisation Type*Please enter the type of organisation HiddenNew OrganisationHidden section that is only shown when the organisation is unknownOrganisation Name*Please enter the name of the organisation Organisation Post Code*Please enter the post code of the organisation Is this an NHS organisation?* Yes No Does this organisation provide any NHS-funded care?* Yes No Don't know HiddenRole* Staff GroupAdditional Clinical ServicesAdditional Professional Scientific & TechnicalAdministrative & ClericalAllied Health ProfessionalsEstates & AncillaryHealthcare ScientistsMedical & DentalNursing & Midwifery RegisteredStudent Job Title Job Title*Please enter your job title Salary/Band*Band 1 or £17,460Band 2 or £17,460 - £18,702Band 3 or £17,787 - £20,448Band 4 or £20,150 - £23,363Band 5 or £23,023 - £29,608Band 6 or £28,050 - £36,644Band 7 or £33,222 - £43,041Band 8a or £42,414 - £49,969Band 8b or £49,242 – £59,964Band 8c or £59,090 - £71,243Band 8d or £70,206 - £85,333Band 9 or £84,507 - £102,506Band VSM or £98,545 and overOther Salary/BandDo not wish to discloseCurrent?*Are you currently active in this role? Please note: we only require past roles if you are unemployed. Yes No 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?*FemaleMaleAnother genderDo not wish to discloseAre you now or have you ever defined yourself as Trans?*YesNoDo not wish to discloseWhich of the following best describes your sexuality?*AsexualBisexualGayHeterosexualAnother sexualityDo not wish to discloseDo you consider yourself to have a disability?YesNoDo not wish to discloseWhich of the following best describes your ethnic background?*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 group - ChineseAny other ethnic groupDo not wish to discloseWhich of the following best describes your religion or belief system?*AtheismBuddhismChristianityHinduismIslamJainismJudaismSikhismOtherNot religiousDo not wish to disclose SummaryFood Allergies* Peanut Allergy Milk Allergy Egg Allergy Wheat Allergy Soy Allergy Fish Allergy Shellfish Allergy Lactose Intolerance Gluten Intolerance Other Food Allergy None Other Food Allergy HiddenWarning for allergies noneDisplays if "none" selected for allergiesYou checked "none". Please uncheck all other options before continuing.Dietary Requirements* Vegan Ovo-Vegetarian Lacto-Vegetarian Lacto-Ovo Vegetarian Pescetarian Kosher Halal Other Dietary Requirement None Other Dietary Requirement HiddenWarning for dietary noneDisplays if "none" selected for dietary requirementsYou checked "none". Please uncheck all other options before continuing. Please complete the following to provide some introductory information about yourself and what you hope to gain from the opportunity to work with a senior mentor. This information will be treated in confidence. It is intended to guide your own reflection in advance of the workshop, to help match you to a mentor who is closely aligned to your goals. It will also provide your mentor with an introduction to you as a basis for discussion between yourselves during your initial engagement.Career History*Please provide a brief career historyKey Achievements*What are some of your key achievements?What are your ambitions in life?*What are your career ambitions?*Experiencing Inequality*How has inequality in the NHS impacted you as a BAME woman?What contribution would you like to make to the NHS?* Why do you want a mentor?*Please use specific reference to the experience of inclusion/equality and your learning from the Stepping Up programme.What would you list as your strengths?*What areas are you looking to improve?*What do you want to gain from having a mentor?*Using context of your participation on Stepping Up for example: · Skills · Approach · Areas of knowledge · Connections SummaryPlease check your details and, if correct, submit this form. {all_fields:value,nohidden,noadmin}