Membership Form

    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:
    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:
     
     
    Once we receive your application, an invoice will be sent to you.