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ASRT Student Leadership Development Program

ASRT Student Leadership Development Program Application
  1. This form is to be completed and submitted by any student interested in applying for the ASRT Student Leadership Development Program. Please review the criteria and information for this position on the Student ConneX page. If selected, I agree to all requirements of the position and will fully support the Code of Regulations of the Society and to conform to the Code of Ethics adopted by the Society.
  2. First Name(*)
    Please provide your First Name.
  3. Middle Name
    Invalid Input
  4. Last Name(*)
    Please provide your Last Name.
  5. Email Address (OSRT will not sell)(*)
    Please enter a valid email of the form This email address is being protected from spambots. You need JavaScript enabled to view it.
  6. Home Phone-No dashes(*)
    Please provide your Home Phone Number.
  7. Cell Phone-No Dashes
    Invalid Input
  8. Ohio Imaging/Radiologic Science Program Name(*)
    Please enter your program/school name.
  9. Program Director Name(*)
    Please enter your Program Director Name.
  10. Program Start Month(*)
    Please enter the month you started your technical studies.
  11. Program Start Year(*)
    Select Program Start Year
  12. Graduation Month(*)
    Please enter the month of your graduation.
  13. Graduation Year(*)
    Please enter the year of your graduation.
  14. Are you currently actively enrolled in technical courses in your program?
    Invalid Input
  15. Are you currently in good standing in your program?
    Invalid Input

  16. To qualify, you must hold current student membership in OSRT and ASRT. If you are not a current student member, you must first apply for membership online and receive an OSRT membership number before submitting this application.
  17. OSRT Member ID#(*)
    Please provide your OSRT membership number located on your membership card.
  18. Narrative Statement - How do you think you would grow professionally from your participation in the ASRT Student Leadership Development Program? (Max of 400 words)(*)
    Please address the importance of professionalism and service to the profession and the Ohio Society of Radiologic Technologists.
  19. Narrative Prepared - Discuss three (3) ways that your experience in the ASRT Student Leadership Development Program would lead to future involvement in the OSRT. (Max of 200 words)(*)
    Are you aware of and prepared to meet the expectations and the time commitment of being student leader?
  20. Please verify that you are human.
  21. This form is to be completed and submitted by any student interested in applying for the ASRT Student Leadership Development Program. Please review the criteria and information for this position on the Student ConneX page. If selected, I agree to all requirements of the position and will fully support the Code of Regulations of the Society and to conform to the Code of Ethics adopted by the Society.