Membership Form

    WESTCHESTER SPEECH, HEARING AND LANGUAGE ASSOCIATION
    MEMBERSHIP APPLICATION
    APPLICANT INFORMATION
    Name*:
    E-mail*:
    Home Phone#*:
    Mobile#*:
    Home Address*:
    City:
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    Zip Code:
    Referred By*:
    EMPLOYMENT INFORMATION
    Current Employer*:
    Employer Address*:
    City:
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    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.