Direct Application

patient centred care master class series

Please be advised that this application must be filled as a group and only ONE application should be submitted per team.

By signing below, your signature acknowledges the following:
This application is for a three‐part master class series. The series includes three, two‐full day sessions, which span the course of six weeks, additionally, there is a three‐month capstone project to be completed as a team within your facility.

Signature of applicants:

Signature 1:

This form field, 'SIGNATURE', constitutes a legally binding signature.

Signature 2:

This form field, 'SIGNATURE 2', constitutes a legally binding signature.

Signature 3:

This form field, 'SIGNATURE 3', constitutes a legally binding signature.

Team Information

Number of Team members: (maximum team size is 3)
Are all team members from the same department?

Facility Information

Facility Name:

Address:

Phone Number:

Website:

If applicable

Email:

Chief Medical Director Information

First Name:

Surname:

Phone Number:

Email:

Personal Information

To be completed for each team member

1.)

First Name:

Surname:

Phone Number:

Email:

Profession:

i.e doctor, nurse, midwife, pharmacist

Specialty/department:

In no more than three lines, please describe your current responsibilities:

2.)

First Name:

Surname:

Phone Number:

Email:

Profession:

i.e doctor, nurse, midwife, pharmacist

Specialty/department:

In no more than three lines, please describe your current responsibilities:

3.)

First Name:

Surname:

Phone Number:

Email:

Profession:

i.e doctor, nurse, midwife, pharmacist

Specialty/department:

In no more than three lines, please describe your current responsibilities:

Has your team ever worked together before? If so, in what capacity? Please keep your answer to less than 100 words

What are your team’s strengths? Please keep your answer to less than 200 words (Please note a strong preference will be given to multidisciplinary teams that work on the same unit within the same facility)

Please use this section to tell us what your goals and objectives are related to attending this programme (Please keep your response to less than 200 words)

Please describe what patient centred care project your team would like to carry out in your facility. Please note, you will be allowed to change your project if enrolled in the program. (Please keep your response to less than 100 words)

Please tell us briefly why we should select your team. (Keep your response to less than 200 words)

How did you learn about this programme?

HLA WebsiteNews Paper AdvertisementWord of MouthSocial MediaBrochure/PamphletOnline AdvertisementNigeria Health Watch

Other:

Please specify

Please note:
If accepted the cost is 75,000 NGN (early bird special) per participant BEFORE March 31st, the cost after the early bird special is 95,000 NGN per participant. Fees are payable to The Healthcare Leadership Academy. Account details will be shared upon acceptance to the course. Full payment must be received prior to the start of the program.

This application form must be fully completed and signed before review.

I certify that the information and accompanying support documentation provided in connection with this application are authentic and accurate.

Thank you! Your submission has been received!

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Direct Application

patient centred care master class series

Team Information

Facility Information

Chief Medical Director Information

Personal Information

1.)

2.)

3.)

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