Application Form

ILM Level 5 Coaching and Mentoring Programme

Coaching and Mentoring An ILM Level 5 in Coaching and Mentoring

This programme is open to anyone who has a strong interest in becoming a qualified coach and working with clients. Suitable participants may already informally coach others and be looking to develop and formalise their capabilities through a qualification, or they might be entirely new to the concept of coaching but have a passion for developing and motivating others, dynamic conversation, iterative learning and active listening.

Course InformationCourse Name ILM Level 5 in Coaching and Mentoring

Course Location Compton House, Exeter, EX2 7HUFee of course Free to attend

Additional feesCancellation Charge £1500Application Deadline 5pm, Friday 5th AprilBooking Conditions Commitment

In order to successfully complete the programme you are expected to attend and complete the programme in full. Please note the workshop dates, and check your diary availability :

Part one: Monday 13th and Friday 17th May | 9.00 - 17:00Part two: Friday 5th and Monday 8th July | 9.00 - 17:00Part three: Friday 13th and Monday 16th September | 9.00 - 17:00Teletutorials will also be arranged with delegates of the programme by the facilitators, once the programme has started.

Assignment requirementsDetails will be confirmed on acceptance to the programme.Please note that the ILM assignment will consist of written essays to be completed, all with a required word count, along with logs of your coaching practice. The deadline for these assignments will also be communicated through the application form process.

Please hold these dates in your diary whilst the application/shortlisting process is taking place.

Data protectionWe will not supply your details to any outside organisation for marketing purposes. The information supplied on this booking form will be retained, unless instructed otherwise on our course database and will be used for all legitimate purposes in connection with the administration and marketing of our course programmes. Please email leadership.SW@hee.nhs.uk if you do not wish to be included in future communications.

CancellationsSuccessful applicants will be liable for the full cost of their place on the programme (as identified in the Cancellation Charge above) should they cancel their secured place or fail to complete the programme, regardless of the notice period provided. Charges won’t apply if the event is cancelled by the organiser.

Delegate Information

Title ☐ Mr☐ Mrs☐ Ms☒ Miss☐ Dr☐ Other (please specify):      

First Name      Surname      

Previous surname(s)      Job Title      

Organisation Name      Work Contact Details

Postal address line 1      Postal address line 2      Postal address line 3      

Postcode      Email Address      

Direct Dial      Mobile Number      

Alternative/PA Contact DetailsAddress line 1      Address line 2      Address line 3      

Postcode      Email address      

Access RequirementsDietary requirements      Access requirements      

Invoicing InformationFor use in case of cancellation

Address line 1      Address line 2      Address line 3      

Postcode      Email address      

Reference number      

Delegate commitment

Statement of CommitmentI agree to:Complete the programme as follows:

Attend all 6 days of highly practical workshops involving exercises focused on developing key coaching competencies, understanding and using processes and tools and importantly, giving you the confidence to get stuck in.

Attend the tele-tutorials as arranged with the facilitator. Coaching practice - at least 12 hours in order to achieve the qualification Reflective Practice – to embed your learning as a coach Group supervision to support reflective practice Completion of a portfolio of learning to capture your development as a coach Upon starting the programme, I will undertake coaching with a minimum of two coachees in

order to achieve my 12 hours of practical coaching experience Upon completion of the programme, I will be an active member of the South West Leadership

Academy register, and will undertake coaching with coachees as requested through the register

I will regularly attend network meetings, supervision and CPD events to support my continuous professional development as a coach and use both supervision and reflective practice to maintain the standard of coaching required by the South West Leadership Academy

I am aware that the Leadership Academy is making a financial investment in my development as a coach and I commit, to the best of my knowledge and ability, to fulfilling all of the required elements of the programme to become accredited as a coach and practice within South West Leadership Academy as part of the coaching network.

I am fully committed to joining the register and working with coaches on a regular basis.

Please sign here to acknowledge your

acceptance of the Booking Conditions above:

(scanned signatures accepted)

      

Executive/Organisational Authorisation

As Executive/Organisational Authorisation, I am committed to supporting the applicant to be able to work with clients upon completion of the programme and will be able to grant the applicant the time from work to undertake coaching.

First name      Surname      

Role ☐ Chair☐ Chief Executive☐ Other (please specify):      

Email Address      Direct Dial      

Mobile Number      Chief Executive/Chair Authorisation

I agree to be bound by the Booking Conditions as outlined in the Course Information above and understand that cancellation penalties will apply should the delegate not complete the course.

I acknowledge that the NHS South West Leadership Academy is not responsible for payment of backfill, accommodation, travel or subsistence.

I agree to provide the conditions, resources and study leave to ensure successful attendance and completion of the entire programme. Where appropriate I will ensure the release of the applicant as appropriate.

I agree to provide ongoing personal support for the applicant’s development.

Please sign here to confirm your authorisation for this individual to undertake the

course as per the above authorisation statements:

(scanned signatures accepted)

      

Question 1Please tell us why you are interested in becoming a coach and what benefits and challenges you see in relation to

coaching as an organisational development and leadership intervention (Maximum 250 words)

ApplicationQuestion 2 What traits, skills, qualities, competencies, interests (and experience, if any) would you bring as a coach? What is it

about you that would make you an effective coach? (Maximum 250 words)

Question 3What do you see as your biggest challenge or area of development for learning to be a coach and practising as a

coach after completing the programme? (Maximum 250 words)

Equal Opportunities Monitoring Form

The NHS South West Leadership Academy (SWLA) are committed to promoting equality and celebrating diversity in line with the Equality Act 2010. SWLA collect and monitor protected characteristics data about participants who access leadership development opportunities to identify how well we are doing and remove barriers to awareness and access to leadership development interventions. This data is collected anonymously. If you are completing this form electronically, please return your completed form to leadership.SW@hee.nhs.uk

1 Name of programme/ workshop/ event

     

2 Gender Female Male Do not wish to disclose

3 Age 16 – 20 21 – 25 26 – 30

31 – 35 36 – 40 41 – 45

46 – 50 51 – 55 56 – 60

61 – 65 66 – 70 71 – 75

I would rather not answer

4 I would describe my ethnic origin as…

Asian or Asian British Bangladeshi Indian Pakistani Any other Asian background

Mixed White and Asian White and Black African White and Black Caribbean Any other mixed background

Other Ethnic Groups Chinese Any other Ethnic Group

Black or Black British African Caribbean Any other Black background

White British Irish Any other White background

I do not wish to disclose my ethnic origin

5 Please select the option which best describes your sexual orientation

Gay woman/LesbianGay manBisexualHeterosexual

Other – please specify below

     

I do not wish to disclose my sexuality

6 Please indicate your religion or belief

AtheismBuddhismChristianityHinduism

IslamJainismJudaismSikhism

Other – please specify below

     

I have no religion/beliefI do not wish to disclose my religion/belief

7 Do you consider yourself to have a disability?

Yes No Do not wish to disclose that information

Professional background

8 Do you have regular contact with patients? Yes No

9 If you answered ‘Yes’ to the question above, do you also hold a managerial role?

Yes No

10 Please specify your professional background (if applicable)

AHP GP Hospital Doctor Manager Medical/ Dental Trainee(delete as appropriate) Nurse/Midwife (delete as appropriate) Scientist Student Nurse/Midwife (delete as appropriate) Other – please specify below

     

11 Please indicate your specialism (if applicable)

FinanceGeneral Management HR IT/Informatics Other – please specify below

     

NOTE: Please return the completed application and equal opportunities form (which can be found below) to: leadership.SW@hee.nhs.uk by 5pm, Friday 5th April.Please note the module dates and check your diary availability.

Your responses to our Equal Opportunities form will be removed from the application form and will remain confidential.

The closing date for applications is 5pm, Friday 5th April.