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

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    Please click once and you’ll be directed to pay.