ATSSA Roadway Safety Leadership Academy Application

ATSSA Roadway Safety Leadership Academy Application
To apply for the 2026-2027 ATSSA Roadway Safety Leadership Academy, you must be an ATSSA member. Please complete and submit this application no later than Friday, May 15, 2026.

ATTENDANCE POLICY AND EVENTS

To successfully complete the program, it is required that participants attend at least 80% of the scheduled classes and events to receive a graduation certificate.

SELECTION AND TUITION

Applicants will receive notification of selection by Friday, June 15, 2026.

If selected, you will be billed for the $2,900 non-refundable tuition. Payment is due no later than Wednesday July 15, 2026.
Name:

First NameLast Name
Title:
Company:
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email:
example@example.com
Company Phone Number:

Area CodePhone Number
Cell Phone Number:

Area CodePhone Number
ATSSA Membership Join Date (year):
GuardrailManufacturers and Service ProviderPavement MarkingSign ManufacturingTraffic Services
ContractorManufacturer and Service ProviderPublic Agency
Primary Chapter:
Chapter President's CouncilGovernment Relations CommitteeGuardrail CommitteeHigh Friction Surface Treatment (HFST) CouncilInnovation CouncilMember Engagement CommitteePavement Marking CommitteePAC Oversight CommitteeRisk Management CouncilRoadway Worker Protection CouncilSafety and Public Awareness (SPA) CommitteeSign CommitteeStrategic Highway Safety Planning (SHSP) CouncilTemporary Traffic Control (TTC) CommitteeTraffic Signals CommitteeWomen In Roadway Safety CouncilYoung Professionals & Emerging Leaders CouncilNone of the Above
Chapter President's CouncilGovernment Relations CommitteeGuardrail CommitteeHigh Friction Surface Treatment (HFST) CouncilInnovation CouncilMember Engagement CommitteePavement Marking CommitteePAC Oversight CommitteeRisk Management CouncilRoadway Worker Protection CouncilSafety and Public Awareness (SPA) CommitteeSign CommitteeStrategic Highway Safety Planning (SHSP) CouncilTemporary Traffic Control (TTC) CommitteeTraffic Signals CommitteeWomen In Roadway Safety CouncilYoung Professionals & Emerging Leaders CouncilNone of the Above
ExpoMidyearLegislative Fly-InCommittee/Council Subcommittees, Task Forces, Working GroupsFoundation Events
Briefly describe your professional experience and goals:
What do you hope to gain by participating in this program?
YesNo
If yes, provide Industry Association name(s):
YesNo
If yes, provide Industry Association name(s):
Should be Empty: