EmailMe Form - RBMA I LEAD Application

Required Questions

Please answer all questions below

Name *

First Last

Credentials (RCC, FRBMA, etc...)

Email *

Company *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Preferred Phone *

### - ### - ####

Are you currently a member of the RBMA? *

Yes

No

I have been a member, but I am not now.

If staff of member, share the member's name:

Areas of expertise (select all that apply): *

Impact and Industry Contribution: What specific, lasting impact do you aspire to make through your participation in this program, and how do you plan to apply what you learn to address key challenges or innovate within the radiology industry? *

Personal Growth and Learning Goals: How do you envision this program shaping your personal and professional development? What specific skills or knowledge do you aim to acquire, and how will these help you grow as a leader in the radiology field?

Program Investment

Total Estimated Program Cost *: $4,699
SYNC 2025 Registration: $629
PaRADigm 2026 Registration: $1,095
RBMA Membership: $475
Estimated Travel Costs **: $2,500

* Limited scholarship funds are available to assist participants, though funding is not guaranteed and may be awarded based on available resources.

** These costs are estimates and may vary, particularly travel expenses, which depend on individual arrangements.

Based on the above outline of the program investment, are you seeking a form of scholarship to apply to be in this program? *

Yes

No

Does your current employer offer financial support towards your professional development? *

Yes

No

How much scholarship are you looking to obtain? *

0-25%

25-50%

50%-75%

75%-100%

Scholarship Impact and Financial Considerations: How will receiving this scholarship enhance your ability to fully engage with and benefit from this program? In what ways would this financial support help you overcome barriers or further empower you to achieve your goals within the radiology field? *

Optional Questions

Answering these questions is optional and does NOT impact your ability to be chosen in the program.

Gender Identity (please select one):

What is your age group?

Are you of Hispanic, Latino, or Spanish origin?

Yes

No

I do not prefer to answer

Race (please select one or more boxes)

Required Uploads

Two letters of recommendation are required:

First Letter: From a colleague or network peer—someone you work with directly in your current role.

Second Letter: From your current employer, specifically from one of the following:

-Physician Leader
-Administrative Leader of your practice or organization
-Director, CEO, or COO of your practice or organization

Additionally, please provide your current resume or CV.

Colleague/ Network Peer Letter *

Employer Letter *

Current resume or CV *

Agreement

Please affirm the following:

1. You have read the RBMA I LEAD program application guide and believe you can meet all requirements

2. Your availability to attend 2025 SYNC, October 5-7, 2025 in New Orleans, La. and 2026 PaRADigm, April 12-15, 2026 in Championsgate, Fl.

*

Yes, I affirm

Signature

Clear