Future Leaders Conference Survey

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					                            Future Safety Leaders Conference (FSLC)
                             Student Attendee Selection Worksheet

ASSE and the FSLC Task Force will limit the number of attendees for this year’s conference to 120. This will
allow the conference to maintain continuity, more efficiently utilize sponsorship dollars, and deliver a better
product for the attendees. Invitations will be extended to each Student Section President and Vice President.
The remaining attendees will be selected based upon criteria outlined below, the recommendations of their
respective Faculty Advisor and a short essay prepared and submitted by potential student candidates. Each
University may nominate up to 10 students for attendance to the conference.

FACULTY ADVISORS: In order for your students to be eligible to attend the 2010 FSLC, please complete the
information and return the completed worksheet to chapterservices@asse.org NO LATER THAN
SEPTEMBER 10, 2010.

STUDENTS: All students wishing to attend the conference are required to submit a two (2) question short
essay worksheet to the FSLC Task Force for consideration of invitation to the FSLC. PLEASE SUBMIT
YOUR ESSAY ALONG WITH THIS SELECTION WORKSHEET. The essay questions are to be completed
on a separate form found on http://www.asse.org/membership/student_fslc.php.

If you have any questions related to the process please contact one of the following FSLC task force members:
Julie Neuleib – jneuleib@asse.org
Don Jackson – djackson@wsoule.com

University: __________________________________________

Total Number of Students enrolled in a Safety, Health or Environmental related major: ______________

Total number of A.S.S.E. Student Section Members: _____________
                    Student Section President                                      Student Section Vice President

 Name :                                                    Name:

 E-mail:                                                   E-mail:

 Membership                                                Membership
   Number:                                                   Number:
The remaining students will be selected based on a combination of factors including, but not limited to: academic
performance, class standing, student section membership, and faculty advisor comments and recommendations.
                     Student Nominee
                                                                                                                    Has previously
                                                                                              Active Student ASSE
                                                         Overall GPA      Class Standing                            attended this
                                                                                                 Member: Y/N
                                                         3.0 or higher   (JR, SR, or Grad)                           conference
                                                                                             Provide Membership #
 Name:                                                                                                                   Y/N

 email:


 Briefly describe why this student should attend this conference.
                          Future Safety Leaders Conference (FSLC)
                           Student Attendee Selection Worksheet


                    Student Nominee
                                                                                                                 Has previously
                                                                                           Active Student ASSE
                                                      Overall GPA      Class Standing                            attended this
                                                                                              Member: Y/N
                                                      3.0 or higher   (JR, SR, or Grad)                           conference
Name:                                                                                     Provide Membership #
                                                                                                                      Y/N

email:


Briefly describe why this student should attend this conference.




                    Student Nominee
                                                                                                                 Has previously
                                                                                           Active Student ASSE
                                                      Overall GPA      Class Standing                            attended this
                                                                                              Member: Y/N
                                                      3.0 or higher   (JR, SR, or Grad)                           conference
Name:                                                                                     Provide Membership #
                                                                                                                      Y/N

email:


Briefly describe why this student should attend this conference.




                    Student Nominee
                                                                                                                 Has previously
                                                                                           Active Student ASSE
                                                      Overall GPA      Class Standing                            attended this
                                                                                              Member: Y/N
                                                      3.0 or higher   (JR, SR, or Grad)                           conference
Name:                                                                                     Provide Membership #
                                                                                                                      Y/N

email:


Briefly describe why this student should attend this conference.
                          Future Safety Leaders Conference (FSLC)
                           Student Attendee Selection Worksheet

                    Student Nominee
                                                                                                                 Has previously
                                                                                           Active Student ASSE
                                                      Overall GPA      Class Standing                            attended this
                                                                                              Member: Y/N
                                                      3.0 or higher   (JR, SR, or Grad)                           conference
Name:                                                                                     Provide Membership #
                                                                                                                      Y/N

email:


Briefly describe why this student should attend this conference.




                    Student Nominee
                                                                                                                 Has previously
                                                                                           Active Student ASSE
                                                      Overall GPA      Class Standing                            attended this
                                                                                              Member: Y/N
                                                      3.0 or higher   (JR, SR, or Grad)                           conference
Name:                                                                                     Provide Membership #
                                                                                                                      Y/N

email:


Briefly describe why this student should attend this conference.




                    Student Nominee
                                                                                                                 Has previously
                                                                                           Active Student ASSE
                                                      Overall GPA      Class Standing                            attended this
                                                                                              Member: Y/N
                                                      3.0 or higher   (JR, SR, or Grad)                           conference
Name:                                                                                     Provide Membership #
                                                                                                                      Y/N

email:


Briefly describe why this student should attend this conference.
                          Future Safety Leaders Conference (FSLC)
                           Student Attendee Selection Worksheet

                    Student Nominee
                                                                                                                 Has previously
                                                                                           Active Student ASSE
                                                      Overall GPA      Class Standing                            attended this
                                                                                              Member: Y/N
                                                      3.0 or higher   (JR, SR, or Grad)                           conference
Name:                                                                                     Provide Membership #
                                                                                                                      Y/N

email:


Briefly describe why this student should attend this conference.




                    Student Nominee
                                                                                                                 Has previously
                                                                                           Active Student ASSE
                                                      Overall GPA      Class Standing                            attended this
                                                                                              Member: Y/N
                                                      3.0 or higher   (JR, SR, or Grad)                           conference
Name:                                                                                     Provide Membership #
                                                                                                                      Y/N

email:


Briefly describe why this student should attend this conference.




                    Student Nominee
                                                                                                                 Has previously
                                                                                           Active Student ASSE
                                                      Overall GPA      Class Standing                            attended this
                                                                                              Member: Y/N
                                                      3.0 or higher   (JR, SR, or Grad)                           conference
Name:                                                                                     Provide Membership #
                                                                                                                      Y/N

email:


Briefly describe why this student should attend this conference.