Leadership Academy Application

Criteria

Qualified applicants to the ASRT Leadership Academy must meet these criteria:

ASRT member for three consecutive years before date of application.
Affiliate member for two consecutive years before date of application.
Have not previously completed the ASRT Leadership Academy.

Preference is given to first time ASRT committee members and first time officers of an affiliate board of directors.

Directions

Due Date: June 30, 2024 by 11:59 p.m. MST.

Complete this form, attach a copy of your current curriculum vitae and affiliate card. This form must be used; no other form will be accepted. Submit application by the deadline to be considered for participation in the next program.

Governance

Personal Profile
* if marked it is required.

* ASRT member number (You must be an active ASRT member)

Curriculum Vitae

Click on the box to select a file. Upload a copy of your Curriculum Vitae.

Affiliate Card

Click on the box to select a file. Upload a copy of your affiliate card.

First Name

Last Name

Street address

City

State

ZIP

Preferred phone

Preferred email

I prefer to receive correspondence by:

Phone
Email

Professional Profile

Job Title

Department

Employer name

Employer street address

Employer city

Employer state

Employer ZIP

Work phone

Work fax

Work email

Affiliate

Which ASRT affiliate do you belong to?

Do you currently or have you previously served on the board of directors or in another volunteer capacity for an ASRT affiliate?

Yes
No

If yes, please list below your position and term.

Education

Institution

Major

Degree Received

Q and A

Please provide a brief answer that explains how participating in the ASRT Leadership Academy would benefit you.

Why do you believe you are a good candidate to participate in the Leadership Academy?

What are your professional goals?

How would participating in the Leadership Academy help you attain your professional goals?

What is your philosophy about ASRT’s role in the health care profession?

What are your plans for volunteering and involvement in the affiliate and ASRT?

Applicant Certification

I submit this application form and the attached curriculum vitae for consideration as a participant in the ASRT Leadership Academy. If chosen, I will comply with ASRT policies and will communicate with the Society in all matters.

By applying for the ASRT Leadership Academy, I understand that if I am chosen, I am also agreeing to apply for a future volunteer commitment with the ASRT or my affiliate society. This volunteer commitment must be for at least one year and shall occur after completion of the program.

* Signature

Date signed

Leadership Academy Application

Criteria

Directions

Governance

Personal Profile * if marked it is required.

Professional Profile

Affiliate

Education

Q and A

Applicant Certification

Have a Question?

Personal Profile
* if marked it is required.