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: You are encouraged to begin the process and send your application as early as possible. Please note that only complete applications are reviewed by the Programme Director and that INSEAD makes all admissions decisions (not the Trust). The selection process seeks to maintain comparable ability and experience and to ensure diversity in country of nationality and place of work. Participants are required to do the pre-requisite readings and write a 5 to 10 pages memo after the programme on a specific project.
Programme held at the INSEAD Middle East Campus in Abu Dhabi:
 12-17 November 2016 Application deadline: 8 September 2016

 11-16 November 2017 Application deadline: 7 September 2017

Family name (in CAPITALS) Mr  Ms  Dr 

First name(s) Preferred first name

Job title

YOUR FUNCTION

YOUR POSITION Chief executive  Governmental/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) 

Health Care Organisation Website

Address

City Country

Telephone Mobile telephone

Fax E-mail

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

Main field of activity

Subsidiary of (if applicable)

Address

City Country

Telephone Fax

PERSONAL INFORMATION

Private address

City Country

Telephone……………………………………………………………….

E-mail address to be used for programme communication

Date of birth (dd/mm/yy) Age….. Male  Female  Nationality

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).

STICH - Page 1 of 3

INSEAD Executive Education

Strategic Innovation for Community Health (STICH) Programme

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 one day per week for three months, following the programme, to implement a high-value change project to improve your organisation and to provide a written summary report (4-10 pages) of your progress at the conclusion of the project?

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

Have you attended previous executive programmes (at INSEAD or elsewhere)? Please give institution, programme and year.

How did you hear about the programme?

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 Fax E-mail

Sponsored by The Trust (tuition fees, refreshments during breaks and lunches on campus). Travel, accommodation and evening meals are at the participant’s own expense. For only those who will need it, support for travel and/or accommodation may be available upon request. Please contact your local J&J affiliate for information.
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 Trust sponsored programmes for the following two years.
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]

STICH – Page 2 of 3

INSEAD Executive Education

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].

From time to time, photographs may be taken of participants in class or in working groups. These photographs will only be used in INSEAD material promoting the programmes. If you have any objections, please contact INSEAD Executive Education, Boulevard de Constance, 77305 Fontainebleau Cedex, France. E-mail: [e-mail]

STICH – Page 3 of 3