APPLICATION FORM

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Event Title: Managers Quality Networking Forum
Date of Event: 21st September 2016 / Time: Registration from 08:30am (event 9.30 to 4 pm)
Venue: Staffordshire County Showground , Weston Road, Stafford, ST18 0BD
Name:
(Print in CAPITALS please) / Job Title:
Service user (i.e. Dom Care, Learning Disability, Residential Care, Day Care, Nursing Care):
Workplace/Organisation Name & Address
(form cannot be processed without this)
Postcode:
(form cannot be processed without this) / Work Telephone:
Work e-mail: (to be used for purposes of this event)
(form cannot be processed without this)
What are your main objectives for attending this event?
To aid our marketing techniques could you please state how you found out about this event?
Please enter any questions for CQC here & we will place on a slide with others for answering during the question time (they will be anonymous).
Any specific requirements to be met? (access, hearing loop, large print etc.) Please state any dietary requirements.

To help with planning please tick the appropriate box to let us know which session/s you will be attending: (circle one A.M. choice and one P.M. choice) see workshop info sheet for more info

AM Workshop Choice / 1 2 - FULL 3 - FULL 4 - FULL
PM Workshop choice / 5 - FULL 6 - FULL 7 - FULL 8
Signature (or typing below) is taken as agreement to attend the event (if allocated a place)
This is a FREE event, however cancellation must be emailed to If you do not have access to email please ensure that you telephone 01785 355795. Failure to notify us of a cancellation or if you cancel within 10 working days or less a charge of £100 will apply. No charge will be made if a replacement member is substituted.
Delegate signature: Line Managers signature:
Date: Line Managers print:
(form cannot be processed without this)
Please complete the form electronically and e-mail to

For Office Use Only- Place Offered □ Declined □ If place not offered please state reason:

Entered on Spreadsheet / □
Confirmation letter sent / □

Workshop Information Sheet

Please pick one of the following for your AM workshop and PM workshop, note the numbers next to the workshop titles and circle the corresponding number on the application form for both of your choices.

AM session workshop choices

1  Royal College of Nursing (RCN) Session – Perils & Pitfalls of Social Media

2  Jim Ellam & Lynne Bowers – Assistive Technology Support Options - FULL

3  Helen Trousdale & Helen Lingham (UHNS) – Personalisation & Making it real - FULL

4  Sarah Taylor – LD Workshop - FULL

PM session workshop choices

5  CQC – Rachel Davis – Current Themes of what Inadequate & Outstanding Look Like (Priority will be given to those who booked onto this workshop for February’s MQNF) - FULL

6  Theresa Allen – SSOTP – Preventing Falls - FULL

7  Craig Cassells – Safeguarding Decisions and the role of DASM - FULL

8  Helen Wilcox – Support for leaders and managers in the domiciliary care sector