OSRT Student Leadership Program Application

OSRT Student Director Application
  1. This form is to be completed and submitted by any first-year student interested in applying for the OSRT Student Director Position. Please review the criteria and information for this position on the Student ConneX page before submitting this application. If selected, I agree to all requirements of the position and will fully support the Code of Regulations of the Society and conform to the Code of Ethics adopted by the Society.
  2. First Name(*)
    Please provide your First Name.
  3. Middle Name
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  4. Last Name(*)
    Please provide your Last Name.
  5. Email Address (Please use personal email rather than program/work email))(*)
    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?
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  16. To qualify, you must hold current student membership in OSRT. If you are not a current student member, you must first apply for membership online and receive a membership number before submitting this application.
  17. OSRT Member ID#(*)
    Please provide your OSRT membership number located on your membership card.
  18. Narrative Statement - Please address the importance of professionalism and service to the profession and the Ohio Society of Radiologic Technologists. (200 words or less).(*)
    Please address the importance of professionalism and service to the profession and the Ohio Society of Radiologic Technologists.
  19. Narrative Prepared - Are you aware of and prepared to meet the expectations and the time commitment of being student director? (200 words or less)(*)
    Are you aware of and prepared to meet the expectations and the time commitment of being student leader?
  20. Narrative Committee - What OSRT Committee would you be interested in and why? (200 words or less)(*)
    Invalid Input
  21. Narrative Issue - What is one issue students in Ohio are currently facing and how can a professional organization address it? (200 words or less)(*)
    What is one issue students in Ohio are currently facing and how can a professional organization address it?
  22. Form Verification
    Enter the text you see in the text field.(*)
    Form Verification<br />Enter the text you see in the text field. RefreshPlease check the validation code and try again.
  24. This form is to be completed and submitted by any first-year student interested in applying for the OSRT Student Leadership 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.

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