Journalism Leaders Programme
Seminar Registration Form
Seminar for which you are registering: ______________________________________ Date of Seminar: _______________________________________________________
PERSONAL INFORMATION Name: First ______________________ M.I. _______ Last ______________________ Preferred Name for Nameplate_____________________________________________ News Organization ______________________________________________________ (Give full name of newspaper, magazine, station, Web site, university, etc.) Circulation/Market Size_ __________________ Web site URL____________________ Position/Title_ __________________________________________________________ Address ________________________________________________________ City______________________ County ____________ Postal Code ________ Country ______ Work Phone (____) _______________ Mobile Phone (____) _______________ E-mail __________________________ Gender Male Female After attending the seminar, do you intend to continue working towards an academic award? Yes NO Experience Number of years in news business___________________________________________ Nominating Editor or Manager______________________________________________ Title________________________________ Phone (________)___________________ News Organization (if different from applicant)_________________________________ Business Address (if different from applicant)__________________________________ ______________________________________________________________________ Editor/Manager E-mail____________________________________________________ Who initiated the process for you to attend a Journalism Leaders Programme seminar? you your supervisor If it was you, how did you learn about the seminar for which you are applying? ____ UCLan course guide ____ Department website (www.ukjournalism.org/jleaders) ____ Special mailing ____ Co-worker Other (please specify)_______________________________________________________ If it was your supervisor, how did he/she learn about the seminar for which you are applying? _________________________________________________________________________ Why did you decide to apply to this seminar?(please check all that apply) ____ Content is applicable to my needs ____ Content is applicable to my organisation’s needs ____ My boss/organisation wants me to attend ____ Time of year course is offered ____ Duration of the course ____ Location ____ Ease of travel ____ Cost ____ Other (please specify) ____________________________________________________ Who is paying for your seminar tuition? I am my employer is shared by employer and me other ________________ Who is paying for your travel? I am my employer is shared by employer and me other ________________ Will you use vacation? Yes / No What are the three best months for you to attend a seminar? Jan. Feb. Mar. April May June July Aug. Sept. Oct. Nov. Dec. Additional comments or instructions for the programme administrators ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
E-mail completed applications to the Journalism Leaders Programme team at: leaders@ukjournalism.org .