WESTCHESTER SPEECH, HEARING AND LANGUAGE ASSOCIATION MEMBERSHIP APPLICATION
APPLICANT INFORMATION
Name*:
E-mail*:
Home Phone#*:
Mobile#*:
Home Address*:
City:
State:
Zip Code:
Referred By*:
EMPLOYMENT INFORMATION
Current Employer*:
Employer Address*:
Setting:
—Please choose an option—Private PracticeHospitalAgencySchool
Other:
PROFESSIONAL INFORMATION
Professional License:
—Please choose an option—SLPAuD
Degree Status:
—Please choose an option—PhD.M.A.M.S.B.A.B.S.Other
NYS Licensure Number:
ASHA Number:
Other Licenses:
Area of Expertise/Interest (check all that apply):
AphasiaCochlear ImplantsHearing Evals/Hearing AidsSound Field SystemsDysphagiaAutismLaryngectomy/GlossectomyMotor SpeechFeedingStutteringVoiceLanguage DisordersAugmentative CommunicationArticulation Disorders
Population Served (check all that apply):
EIPreschoolElementary SchoolMiddle SchoolHigh SchoolAdultsMixed
If you are in private practice, do you take insurance?:
—Please choose an option—YesNo
MEMBERSHIP
Membership Status:
—Please choose an option—First time MemberRenewing Membership
ASHA certified and/or NYS Licensed SLPs and AUDs- $50Clinical Fellows- $25Student- $10
WSHLA INFO & AVAILABILITY
I am available to work on Committees*:
YesNo
I am interested in presenting a program*:
Topic of Interest:
PAYMENT
Total Amount:
Please click once and you’ll be directed to pay.