Leading Transformation in Learning and Teaching
Application Form
We would encourage applicants to undertake the full programme: all three modules plus on-line action-learning (AL). This will provide
the opportunity for a more extended learning experience interspersed with time for both reflection and the application of ideas.
LTLT 2 (Application Deadline: 11 October 2013)
Module One:
Wednesday 6 and Thursday 7 November 2013
Module Two: Tuesday 3 December 2013
Module Three: Thursday 30 January 2014
Action learning Sets: February to April 2014
LTLT 3 (Application Deadline: 14 February 2013)
Module One:
Wednesday 5 and Thursday 6 March 2014
Module Two: Tuesday 8 April 2014
Module Three: Thursday 15 May 2014
Action learning Sets: May to July 2014
Programme Fees for Member Institutions:
Full Programme: £1,995*
Includes Module 1, 2 and 3 and 2 on-line action-learning sets
Module One: £1,295*
OFFICE USE ONLY
SO Number
IN Number
CN Number
Modules One and Two: £1,695*
* Your institution must be a member of either the Leadership Foundation or the Higher Education Academy, for the members’ fee to apply.
Please note that places on the ‘Leading Transformation in Learning and Teaching Programme’ are offered on a ‘first come first served’ basis, once we
have received a completed booking form and the supporting information.
If your institution runs a purchase order system, please send a purchase
order/purchase order reference with your application.
Title:
Prof
Dr
Mr
Mrs
First Name:
Ms
Miss
Other
Preferred Name:
Family/ Last Name:
Position Held:
Department:
Institution/Organisation:
Address for correspondence:
Invoice address (if different)
Postcode:
Postcode:
Delegate Email:
PA’s Email:
Delegate Mobile:
PA’s Name:
Delegate Direct Line:
PA’s Phone:
Special Dietary Requirements
Vegetarian
Vegan
Food allergies please state:
Halal
Kosher
No Seafood
No Dairy
Other requirements:
How To Apply: You need to send in answers to the following points on a separate sheet (in no more than 400 words),
with your completed application form to apply for the Leading Transformation in Learning and Teaching Programme.
Please tick to confirm you have enclosed the information requested below.
If you currently have a specific focus for transforming learning and teaching, what area is this?
(This could be concerned with employability, assessment and feedback, updating content, moving from modularisation to
different approaches, creating on-line provision or a combination of areas, with one having priority).
This programme will help you to develop a transformation initiative that you have in mind, even if only at the initial
stages. If you don’t have an initiative, the programme will help you to develop broader potential in this area for future use.
I have a specific transformation initiative in mind:
Yes
No
If Yes, please describe it in around 100 words, including timescale.
Applicants applying for the full programme (Modules One, Two, Three and On-line Action-Learning )
Please provide a brief outline (no more than 200 words) of your ideas for a learning and teaching transformation
initiative you will use as the basis for your Transformation Pilot. Please include anticipated benefits (eg to students, to
staff, and to institution).
* Fee for Non-Member Institutions:
Module One: £1,615
Modules One and Two: £2,115
Three Modules: £2,495
Leading Transformation in Learning and Teaching
Application Form
EQUAL OPPORTUNITIES MONITORING QUESTIONNAIRE
We are committed to, value, and respect the diversity of higher education and we want to ensure that all people are treated fairly when
accessing our programmes, events and services, irrespective of race, sexual orientation, disability, gender or religion. By completing this
form you are helping us to ensure that everyone who takes part in our activities is treated equally. Your information will be confidential
and your name will not be linked to the data when we monitor or report on it. We shall be using the data to let institutions know how our
programmes are accessed. Thank you.
1 Ethnic Background
(please tick as appropriate)
Prefer not to say
White
English/Welsh/Scottish/Northern Irish/British
Irish
Gypsy/Irish Traveller
White and Black African
White and Asian
Other White background (please specify)
Mixed/Dual Heritage
White and Black Caribbean
Other Mixed / Dual Heritage (please specify)
Asian or Asian British
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background (please specify)
Black/African/Caribbean/Black British
African
Caribbean
Other Black/African/Caribbean background (please specify)
Other Ethnic Group
Arab
2 Disability
Other ethnic group (please specify)
Prefer not to say
Do you consider yourself to be disabled or have a long term health condition?
Yes
No
Do you have any requirements?
Yes
No
If Yes, what assistance can we offer you?
We are able to offer the use of portable induction loop hearing system. Please tick if you require this.
If you indicate on this booking form that you have any requirements due to a disability or for any other reason, we will contact you before the
programme starts to go through any arrangements that need to be made.
3 Gender
Prefer not to say
I am male
I am female
4 Religion
Prefer not to say
No Religion
Buddhist
Christian (including Church of England, Catholic, Protestant and all other Christian denominations)
Hindu
Jewish
Muslim
Sikh
Heterosexual/straight
Bisexual
Other religion (please specify)
5 Sexual Orientation
Gay man
Prefer not to say
Gay woman/lesbian
Other sexual orientation (please specify)
To Book: Please complete this form and return it by post, fax or email to: Lucy Matthews, Programme Development Officer
Leadership Foundation for Higher Education, Peer House, 8-14 Verulam Street, London WC1X 8LZ
T: 020 3468 4827 F: 020 3468 4811 E: [email protected]
Invoices are issued prior to the programme start date. Payment can be made by bank transfer, cheque or credit card.
Cancellations: All cancellations must be made in writing (post, fax or email) to the Leadership Foundation. Please contact Lucy Matthews
E: [email protected] to cancel your place on this event.
Please visit the Leadership Foundation website for the full Terms and Conditions including the cancellation policy: www.lfhe.ac.uk/cancellation. The
Leadership Foundation will not be responsible for any expense incurred in the lead up to the event. Should the event be cancelled we will not reimburse
for any expense incurred.
Data Protection Act: Booking on this event means you have agreed to the Leadership Foundation storing your booking details electronically in order to
process applications, invoices and to send you information about our other programmes, events and services. Your information will not be shared with
third parties.
Modified: 9 September 2013