2023 Scientific Display (Poster) Entry Form

Title of Display *

Name of Student 1 *

Email Address *

TSRT Membership ID Number *

TSRT Membership Expiration Date *

Name of Student 2

Email Address

TSRT Membership ID Number

TSRT Membership Expiration Date

Additional Participants (3 or more students)

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If more than two students are collaborating on a poster, please create a document with the following information for all students. Name, Email, TxSRT ID Number, TxSRT Expiration Date.

Please read and acknowledge each statement. Be advised failure to acknowledge all applicable statements may result in an incomplete application *

I (We if representing each member of our team competing in this competition) acknowledge that I am/we are currently enrolled in an accredited medical imaging or radiation therapy program.
I (We if representing each member of our team competing in this competition) acknowledge I am/we are not currently registered in any primary medical imaging or radiation therapy modality.
I (We representing each member of our team competing in this competition) acknowledge I/we will be subject to disqualification if the above acknowledge are verified as inaccurate or not compliant with qualifying standards.

Name of School *

Name of Program Director *

Program Director's Email *

Contact Telephone Number *

Upload Digital Poster Here *

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Upload Letter of Verification *

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The Program Director must complete and sign the letter of verification for your student status. Please note the same letter of verification may be submitted under each applicable competition. The attached letter from your Program Director must be on college/school letterhead and the date should not exceed 2/1/2021. *** One submission for the entire team is acceptable. Please ensure each students name is indicated on the submitted form ***

I / We have read the above rules and regulations. I/ We understand and agree to abide by these rules and regulations governing the Scientific Display Competition. *

Agree

Name