Expression of Interest Form

Yes… Please allocate me a place on the My Home Life Leadership and Professional Support programme for NW London Care Home Managers

My name is: ...................................................................................................................................

The home I manage is called: ............................................................................................................

Address: ...............................................................................................................................................

..................................................................................................................................................

Borough: ..................................................................................................................................................

Postcode: .................................Phone..................................    Email……………………….......................

The home I manage is a residential care home /nursing care home (please delete) for:

Older people 

Dementia

Declaration

I confirm that:

1. I have the support of the owner of the care home I manage/my line manager to take part in the My Home Life leadership development programme.

2. I understand that by participating in this programme I am expected to commit to attend all of the required sessions and that failure to attend all of the required sessions may jeopardise the success of the programme and the benefits to me and the care home I manage.

3. I understand that spaces are limited and cannot be reallocated to another manager if I withdraw from the programme.

Signed: .....................................	Print name: ..................................... Date: .....................................

PLEASE EMAIL TO: MHL@city.ac.uk, you will hear from us shortly.

Please ensure that your completed expression of interest form is returned to the address below by

INSERT DATE
INSERT EMAIL OF PERSON RECEIVING THE APPLICATION FORMS.

Please tick your preferred start date: 
Feb 2018 
March 2018
April 2018