Young Managers

INSEAD Executive Education

Strategic Innovation for

Community Health (STICH)

Programme

Please include a recent passport type photograph (electronic preferable)

PERSONAL APPLICATION FORM

Please write clearly in black and make a copy for your own records
APPLICATION PROCEDURE

Please send your application form as early as possible. Note that only complete applications are reviewed by the INSEAD Admissions Committee. INSEAD makes all admissions decisions (not the Trust). Participants are required to do the pre-requisite readings before the programme, and report back after the programme on a specific project.

 12 - 17 November 2018 Application deadline: 12 September 2018

Programme is held in Nairobi (Kenya). Venue will be communicated after enrolment, approximately 6 weeks before.
Family name (in CAPITALS)  Mr  Ms /Mrs  Dr

First name(s) Preferred first name

Job title

YOUR FUNCTION

YOUR POSITION Chief executive  Government official ^1  Policy maker Clinical director, chief of service, group head of function  and/or reports directly to Chief executive Reports directly to 2 (above)  Not covered by the above (please specify)  …………………………………………………………………….…..

Description of duties (responsibilities; also indicate the title of the person to whom you report directly; as well as the number of people and the size of the budget or amount of revenue that you manage).
Health Care Organisation Website

Address

City……………………………………………………………. Country …………………………………………………………………..

Telephone…………………………………………………….Mobile telephone ………………………………………………………………….

E-mail

Number of employees Annual Budget or Revenue (in Euro or US $)

Main field of activity

Subsidiary of (if applicable)

Address

City ……..….Country…………………………………………………………………………………

Will your organisation pay for your:  Travel  Accommodation. If not, please explain why it will not fund you

If you wish to apply for a scholarship, please contact: Tinneke Proost at [e-mail] right after your enrolment in the programme, and no later than 22^nd September. The Trust will share the scholarship application form and eligibility criteria by email (employees of existing J&J partners and Nairobi based candidates will not be granted a scholarship). Should you not be eligible to a scholarship, please confirm whether your application is

 Conditional of receiving a scholarship  Not conditional of receiving a scholarship

PERSONAL INFORMATION

Private address

City………………………………………………Country …….………………Telephone…………………………………………..…

E-mail address…………………………………………Date of birth (dd/mm/yy)………….…………..Nationality…...………………………

OTHER INFORMATION

Elaborate here on any special experience you think relevant to your application.
What are 2 key challenges or opportunities you are faced with today in your organisation? What are the cultural, political or technical barriers to change? How can the programme with these challenges?

Do you agree to invest 1 day per week for 3 months following the programme, to implement a project aiming at transforming health, to improve your organisation, and to respond to survey on your progress during and at the conclusion of the project?

 Yes  No  Maybe Comments:

Education at the university level. Dates attended, degrees received.

Have you attended any programmes at INSEAD, Johnson & Johnson funded programme, or other executive development programme in the past? If so, which programme/s and with which training institution?

How did you hear about the programme?

 Through search  Through INSEAD communication/social media  Through J&J communication/social media  From a past participant / colleague (please fill name below)  Through other means (please specify below)

Please give the name of the senior Human Resource executive in your organisation, and request that person to fill out and submit the attached “Health Care Organisation Application Form” to recommend you to the programme.

Family name (in CAPITALS) First name

Job title Health Care Organisation

Address

City………………………………………………………………. Country…………………………………………………………………………….

Telephone ……………… E-mail………………………………………………………………………………

Covered by The Trust (tuition fees, refreshments during breaks and lunches on campus). Travel, accommodation and evening meals are at the participant’s own expense.
Please note that last minute cancellations or “no shows” without warning and justifiable reasons will not be accepted. Should this happen, both the candidate and the organisation the candidate is coming from, will not be allowed to participate to any of the INSEAD-Trust partnered programmes for the following two years.
Photographs and videos may be taken of participants individually or as a group, in class, in working groups or in social settings. These photographs and videos will be used in INSEAD and Johnson & Johnson materials communicating about, promoting and advertising the programme, through printed and electronic materials, as well as on social media. If you have any objections, please contact: [e-mail]


Applicant’s Signature Date

Application to the programme: Please complete this form and return to [e-mail] or to Professor Stephen Chick [e-mail]

Questions / inquiries related to the programme: Please contact Sabrina Morisset, INSEAD Europe Campus, Boulevard de Constance, 77305 Fontainebleau, France Tel: [phone] Email: [e-mail]

Strategic Innovation for

Community Health (STICH)

Programme
Confidential
HEALTH CARE ORGANISATION APPLICATION FORM

Please write clearly in black and take a copy for your own records.

This Health Care Organisation application for admission should be completed by a senior executive and returned with the Personal Application Form.

IMPORTANT: INSEAD must receive a complete STICH Application Form to consider any candidate.

Name of applicant

Health Care Organisation

Please state your reasons for nominating this applicant and summarise his/her potential for future responsibilities in your organisation.
Do you agree to allow the applicant to spend one day per week during the three months following the course to pursue a high-value improvement project within your organisation? Which activity of lesser value will the participant be excused from doing during the project period in order to create time for the improvement project?


SPONSORING EXECUTIVE
By his/her signature below, the sponsoring executive confirms that the applicant has excellent command of English, that he/she will be completely free of company duties during the programme.

Family name (in CAPITALS) First name

Job title Health Care Organisation

Address

City Country

E-mail………………………………………..Telephone .Fax

Sponsoring Executive’s Signature Date

This Application for Admission should be completed and returned to: [e-mail] or to Professor Stephen Chick ([e-mail])

For questions related to the Programme, please contact: Sabrina Morisset, INSEAD Europe Campus, Boulevard de Constance, 77305 Fontainebleau, France

Tel: [phone], Email: [e-mail]
The personal information collected on completing this application is confidential and secured. Your personal information is intended to be used by INSEAD, its representatives and divisions for administration purposes and to keep you posted on INSEAD Executive Education relevant news.You have the right, on compelling legitimate grounds, to object to the collection and processing of your personal information. INSEAD is the owner of the database and controls the data processing collected by virtue of this application. The French supervisory authority (“Commission Nationale de l’Informatique et des Libertés”) has been notified of this process. You are granted statutory rights of access, modification, update and deletion of your personal information (“Loi n°78-17 du 6 janvier 1978 relative à l’Informatique, aux Fichiers et aux Libertés” as amended). You may exercise these rights by writing or sending an e-mail to INSEAD at the address indicated below. You consent to the transfer of your personal information to INSEAD’s representatives and divisions located outside the European Union, with the knowledge that INSEAD guarantees security and confidentiality. If Client and or Participant object to this transfer, Client and or Participant must contact INSEAD at the following address: INSEAD, Executive Education, Boulevard de Constance, 77305 Fontainebleau Cedex, France. Email: [e-mail].

1 “Government Official” in the context of the FCPA, means any official or employee of a government agency or instrumentality of the government, political party, party official or candidate, or public international organization, such as some non-governmental organizations (NGOs).  The concept of Government Official is broadly interpreted to include Health Care Professionals employed by or acting on behalf of a health care entity, owned or controlled by a government body, such as public hospitals or state universities.

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