NCSRT Leadership Academy Application

First name

Last name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Personal Email Address

Preferred method of communication

Text Message

Phone Call

Which of the following describes your current role?

Imaging Educator

Registered Imaging Technologist working in a clinical setting

Imaging Manager

Student

What prior experience do you have with the NCSRT, Inc.?

In no more than 300 words, briefly share the reasons you are interested in participating in this program.

In no more than 300 words, describe the personal strengths you possess which would enhance the Leadership Academy program as well as the imaging profession.

In no more than 300 words, describe your definition of leadership and give an example of how you demonstrate leadership in the clinical or classroom setting.

Upon successful completion of the NCSRT, Inc. Leadership Academy, it is expected the graduates continue to support the NCSRT by participating in NCSRT activities. Which activities are you most interest in?

Board of Directors Position

Speaking at a Conference or CE Event

Participating in conference or event planning

Joining the legislative efforts to support imaging technologists in NC

Chairing or serving on a committee

General volunteering (ie. annual conference volunteer)

Other

If accepted into the Leadership Academy, you will receive free conference registration at the next annual conference. Are you available to attend the conference?

Yes