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The Sussex Heart Charity

Improving the lives of people with heart conditions in Sussex

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EDUCATIONAL/CONFERENCE BURSARY APPLICATION FORM ESHT

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EDUCATIONAL/CONFERENCE BURSARY APPLICATION FORM ESHT

Before you begin

Which NHS Trust do you work for? *East Sussex Healthcare NHS TrustUniversity Hospitals Sussex NHS Foundation TrustOther / I’m not sure

This is the ESHT bursary application form.

As you work for University Hospitals Sussex NHS Foundation Trust, please use our UHSussex Educational Bursary Application Form instead.

This bursary scheme is for eligible cardiac staff within UHSussex and ESHT.

If you're unsure which form you should complete, please contact the Sussex Heart Charity.

About You

Full name *

Job title / role *Helper text: e.g. Staff Nurse, Cardiac Physiologist, ACP, Healthcare Assistant

Area of work / cardiac service *Helper text: e.g. Cardiac Rehabilitation, CCU, Cath Lab, Cardiac Physiology, Heart Failure, Arrhythmia or ACHD

Main hospital / work location *

NHS email address *

Approval & other funding

Has your line manager approved this application? *YesNo

Please obtain your line manager’s approval before submitting your application.

Line manager’s name *

Line manager’s NHS email address *

Have you explored other sources of funding for this course or conference? *YesNo

Please explore any available Trust, departmental or professional-development funding before applying to the Sussex Heart Charity.

What was the outcome? *No alternative funding was availablePartial funding was availableI have applied and am awaiting a decisionOther

Please briefly explain *

Course or conference

Course or conference title *

Organiser / provider *

Is there an official webpage for the course or conference? *YesNo

Course or conference websitePlease provide a link to the organiser’s official webpage showing details of the course or conference.

Please upload evidence of the course or conferenceFor example, an event programme, course information, invitation or booking information showing the organiser and dates.

No file chosen

Start date *

End date *

How will you attend? *In personOnlineHybrid

Venue / location *

Costs and funding requested

Please tell us the costs associated with attending and the amount you are requesting from the Sussex Heart Charity.

Course or conference fee

Estimated travel costs

Estimated accommodation costs

Total estimated cost

£

Amount requested from SHC *

GBP

Are any of these costs being shared with another attendee? *YesNo

Please provide details of the shared costs *

Are you receiving funding towards these costs from another source? *YesNo

Funding source *

Amount of other funding *

Please provide evidence of your proposed costs *Please provide a breakdown of the costs you are claiming and include links to the relevant course/conference, travel and accommodation information where available. You may copy and paste prices or booking details from the relevant websites.

Benefit of attending

How will attending benefit your professional development? *Please explain what knowledge, skills or experience you expect to gain from attending.

How will this benefit your service and/or cardiac patients? *Please explain how you expect to use what you learn to improve your service, support colleagues or benefit patient care.

Supporting the Sussex Heart Charity

Our Educational Bursary programme is funded by charitable donations. In return for this support, we ask successful applicants to help us demonstrate the difference our funding makes to cardiac staff and patients across Sussex.

If your application is successful, we will ask you to provide evidence of attendance and complete a short post-event feedback form. We may also ask for a suitable photograph, short testimonial or other material that helps us share the impact of the bursary programme.

I understand that, if my application is successful, I will be expected to provide post-event evidence and feedback to help the Sussex Heart Charity demonstrate the impact of its bursary programme.

Educational Bursary communications

If your application is successful, your email address will be added to our Educational Bursary recipient list. We use this list to send information relating to the bursary programme, including award information, post-event requirements, evidence and feedback, payment arrangements and other important programme updates.

This is separate from the Sussex Heart Charity’s general mailing list. Please see our Privacy Policy for more information about how we use your personal information.

Keep in touch with the Sussex Heart CharityYes, I would also like to receive the Sussex Heart Charity’s email newsletter and updates about its work.

Would you be happy for us to contact you about sharing the impact of your bursary publicly? *This might include a photograph, quotation or short testimonial for our website, newsletter, social media or other charity communications.YesNo

Declaration

Please check your application carefully before submitting it. By confirming below, you are agreeing to the conditions associated with an SHC Educational Bursary.

Read the Educational Bursary Terms & Conditions

By submitting this application, I confirm that:

the information I have provided is accurate and complete
my line manager has approved this application
I have explored other appropriate sources of funding
this application is being made before the course or conference takes place
any bursary awarded will only be used for the purpose described in this application
I will provide evidence of attendance and complete the required post-event feedback before payment
I will provide receipts, invoices or other evidence of expenditure if requested
I will notify the Sussex Heart Charity if the course, conference or my circumstances change
I have read and agree to the Educational Bursary Terms & Conditions

I confirm that I have read, understood and agree to the declaration above.

The information provided in this form will be used to assess and administer your bursary application. Please see our Privacy Policy for information about how we use and protect your personal data.

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