Membership Form

WESTCHESTER SPEECH, HEARING AND LANGUAGE ASSOCIATION
2019 MEMBERSHIP APPLICATION
APPLICANT INFORMATION
Name:

E-mail:
Home Phone#:
Mobile#:

Home Address:

City:
State:
Zip Code:

EMPLOYMENT INFORMATION
Current Employer:

Employer Address:

City:
State:
Zip Code:
Setting:
Other:

PROFESSIONAL INFORMATION
Professional License:

Degree Status:

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?:

MEMBERSHIP
Membership Status:

WSHLA INFO & AVAILABILITY
I am available to work on Committees:
YesNo

I am interested in presenting a program:
YesNo
Topic of Interest:

PAYMENT
Total Amount: