Main Organization name
Web page
Address
City
Country
Main contact person name
Main contact e-mail
No. of team participants (3 - 7)
Speciality, field of care or organisation
Primary
Hospital
Tertiary
Counselling
Other
Other specialitity
Field of application
Diagnosis
Treatment
Patient follow-up
Management/administration
Infrastructure/maintenance
Innovation
Other
Other field of application
Your unmet needs
(Please enter:
the high-level description of the experienced issues and felt needs your team would like to work on during the training;
how the experienced issues and felt needs are impacting the healthcare delivery of your service/unit/healthcare organization/etc.;
the expected outputs/outcomes once they are addressed (eg.: reduction of mortality rate, increase of quality of life, reduction of waiting list, improvement in health outcomes, etc.);
the identified entities/stakeholders affected by the experienced issues and felt needs;
the high-level description of the state of the art to demonstrate that the identified problem, issue, need is unmet.
)
Participant 1
First Name
Last name
ID Card
Gender
Female
Male
Prefer not to say
E-mail
LinkedIn URL
Short Biography
(Please provide your English level oral and written, and highlight any work experience, research project, article you published, study you performed, etc., relevant to the problem, issue, need identified by your team, your state role in the organization and your experience with innovation)
Motivation and Engagement
(Please enter your perspective on the problem, issue, need identified by your team, describe how they are influencing your currently way of doing and how it would impact your work if addressed)
Others comments
(Please explain why you join together, what is the support you have from the organization or any other issue that you consider interesting to share with us)
Participant 2
First Name
Last name
ID Card
Gender
Female
Male
Prefer not to say
Organization name member 2
E-mail
LinkedIn URL
Short Biography
(Please provide your English level oral and written, and highlight any work experience, research project, article you published, study you performed, etc., relevant to the problem, issue, need identified by your team, your state role in the organization and your experience with innovation)
Motivation and Engagement
(Please enter your perspective on the problem, issue, need identified by your team, describe how they are influencing your currently way of doing and how it would impact your work if addressed)
Others comments
(Please explain why you join together, what is the support you have from the organization or any other issue that you consider interesting to share with us)
Participant 3
First Name
Last name
ID Card
Gender
Female
Male
Prefer not to say
E-mail
Organization name for member 3
LinkedIn URL
Short Biography
(Please provide your English level oral and written, and highlight any work experience, research project, article you published, study you performed, etc., relevant to the problem, issue, need identified by your team, your state role in the organization and your experience with innovation)
Motivation and Engagement
(Please enter your perspective on the problem, issue, need identified by your team, describe how they are influencing your currently way of doing and how it would impact your work if addressed)
Others comments
(Please explain why you join together, what is the support you have from the organization or any other issue that you consider interesting to share with us)
Participant 4
First Name
Last name
ID Card
Gender
Female
Male
Prefer not to say
Organization name for member 4
E-mail
LinkedIn URL
Short Biography
(Please provide your English level oral and written, and highlight any work experience, research project, article you published, study you performed, etc., relevant to the problem, issue, need identified by your team, your state role in the organization and your experience with innovation)
Motivation and Engagement
(Please enter your perspective on the problem, issue, need identified by your team, describe how they are influencing your currently way of doing and how it would impact your work if addressed)
Others comments
(Please explain why you join together, what is the support you have from the organization or any other issue that you consider interesting to share with us)
Participant 5
First Name
Last name
ID Card
Gender
Female
Male
Prefer not to say
E-mail
Organization name for member 5
LinkedIn URL
Short Biography
(Please provide your English level oral and written, and highlight any work experience, research project, article you published, study you performed, etc., relevant to the problem, issue, need identified by your team, your state role in the organization and your experience with innovation)
Motivation and Engagement
(Please enter your perspective on the problem, issue, need identified by your team, describe how they are influencing your currently way of doing and how it would impact your work if addressed)
Others comments
(Please explain why you join together, what is the support you have from the organization or any other issue that you consider interesting to share with us)
If the team consists of more than 5 members, fill in the following field with all the members' data as above.
Others members
The training fee is 5000 Euro per team (VAT excluded) . The fee includes training programs, study materials, mentoring and networking tools. Once your register has been approved (feedback will be provided in less than 10 days from your application after checking that you fulfil the criteria to get the best from the course), you will get a proforma invoice.
You are kindly asked to proceed with the payment within 30 working days from the receipt of the proforma invoice via bank transfer (or credit card – Visa/Mastercard). Please refer to the guide for applicants for more detailed information.
Billing address and VAT
Send
