CSHA Professional Membership Application

Print and Mail or Fax Form - Click here for Membership Application
THIS MEMBERSHIP APPLICATION IS FOR NEW MEMBERS ONLY!!!
MEMBERSHIP OPTIONS:
Professional/Associate One Year Membership - $135.00 (Membership through Dec. 31, 2014)
Professional/Associate Two Year Membership - $250.00 ($20 discount! through Dec. 31, 2015)
Paraprofessional(SLPA) One Year Membership - $45.00 (Membership through Dec. 31, 2014)
Student/CFY Membership One Year Membership - $35.00 (Membership through Dec. 31, 2014)

GRADUATION YEAR FOR CFY MEMBERSHIP:
2012     2013     2014     2015

AMBASSADOR SPONSOR:

INTERESTED IN VOLUNTEERING?
Yes (We will email you with more information)

PERSONAL INFORMATION:
*First:
    *Last:
    MI:
Preferred Mailing Address (this will be the basis for your district representation; choose either work or home)
*Street Address:
    Apt/Suite #:
*City:
    *State:
    *Zip:
Home Phone:
    Work Phone:
    Fax:
    Cell Phone:
*Email:

CSHA has Gone Green! Future dues notices, district workshop flyers, board highlights, legislative updates, & association announcements will all be sent via e-mail. Please provide your e-mail address. Please know that many school districts block group e-mail notices. If you think your work setting blocks group e-mail notices, please provide us with an alternate e-mail address.

**MEMBER DIRECTORY LISTING INFORMATION:
Do not list me in either directory: Your contact information will not be included in the Online Directory or the Printed Directory. Only your name will be listed. This will allow you to have access to the online directory; however, you will not be able to make changes to your online contact information.
Please include all contact information in both directories: All contact information will be included in both directories. This includes address, home phone, work phone, fax, & email. You will have full online access to update your contact information. Please check all listing preferences that apply in the appropriate boxes below.
 Address
 Home Phone
 Work Phone
 Cell Phone
 Fax
 Email
 All Contact Information

EMPLOYMENT INFORMATION:
Professional Title at Place of Primary Employment: (check one)

A. Dept Chair

B. Professor

C. Assoc. Prof.

D. Assist. Prof.

E. Instructor

F. Director of

G. Audiologist

H. Teacher, Hrng. Impaired

I. Sp. Lang. Pathologist

J. Sp. & Hrng. Consultant

K. Resource Specialist

L. Sp. Lang. Path. & Aud.

M. Supervisor, Special Ed. Svcs.

O. Program Specialist

P. Retired

Q. Not Presently Employed

R. Supervisor, DIS

S. LH Teacher

T. General Ed. Teacher

U. Other

Place of Employment:

PRIMARY & SECONDARY EMPLOYMENT
Primary
Schools, Public
Schools, Non-Public
Private Practice
Academic, College/University
Clinic, Medically Based
Clinic, College/University Based
Community Agency or Clinic
Medical Center
 
Avg. Caseload
#Dup:  
#UnDup:  
Secondary
Schools, Public
Schools, Non-Public
Private Practice
Academic, College/University
Clinic, Medically Based
Clinic, College/University Based
Community Agency or Clinic
Medical Center

AREA OF SPECIALTY:
Specialty:  
Children:
0-3 years
3-5 years
5-17 years

EDUCATIONAL INFORMATION
Institution:  
Undergrad/Masters:  
Graduation Month:  
Year:  
Part-Time/Full-Time:  
Highest Degree:
B.A.
B.S.
M.A.
M.S.
M.Ed.
Ph.D.
Ed.D.
A.A. (SLPAs)
Other  

CERTIFICATION & LICENSURE
CCC Audiology
CCC Speech Pathology
Lang., Speech, & Hrng Specialist Credential
Teacher Hearing Impaired Credential
Educational Audiologist Credential
Administrative Services Credential
Audiologist
License in Speech-Language Pathology
Bilingual Cross-Cultural, Lang & Academic Cert.
Specialty Certification:  
Hearing Aid Dispenser's License
CFY in Audiology
RPE in Audiology
CFY in Speech Pathology
RPE in Speech Pathology
SLP-A
S.P. License #:  
Exp. Date:  
Aud. License #:  
Exp. Date:  

PERSONAL INFORMATION
Sex: Male Female      
Age Group: 20-29 30-39 40-49 50-65 65+
Membership in Other Organizations:
ASHA
CEC
ACSA
CTA
CRA
CAA
AAA
NSSLHA
OTHER:   
Areas of Interest:
1st 2nd
Audiology, Education & Habilitiation of the Hearing Impaired
Education & Habilitation of Children with Severe Language Disorders
Professional Preparation (includes master clinicians, supervisors of CFYs and RPEs)
Speech, Language & Hearing Services in Medical Rehab Centers and Community Agencies
Language, Speech & Hearing Services in the Schools
Community Colleges

BILINGUAL AGREEMENT
Individuals who wish to be listed as Bilingual Professionals must click the BILINGUAL AGREEMENT, that indicates that they have read and concur with the following definition of a Bilingual Professional:
To be listed as a bilingual speech-language pathologist or audiologist you must be able to speak English as your primary language, and speak (or sign), at least one non-English language with native or near-native proficiency in lexicon (vocabulary), semantics (meaning), phonology (pronunciation), morphology/syntax (grammar), and pragmatics (social interaction or social nuances) during clinical management. Additionally, the following abilities are necessary in order to provide appropriate bilingual assessment and remediation services in the client’s language:
  1) Ability to describe the process of normal speech and language acquisition to both bilingual and monolingual individuals, and how those processes are manifested in oral (or manually coded) and written language;
  2) Ability to administer and interpret formal and informal assessment procedures to distinguish between communication differences and communication disorders in oral or (manually coded) and written language;
  3) Ability to apply intervention strategies for treatment of communication disorders in the client’s language, and
  4) Ability to recognize cultural factors which affect the delivery of speech-language pathology and audiology services to the client’s language community.
 
FOREIGN LANGUAGES:
Spanish
Chinese, Mandarin
Chinese, Cantonese
Tagalog
French
Korean
Vietnamese
Sign Language-ASL
German
See Sign
Yiddish
Italian
Hebrew
Other  

Comments:  

REQUIREMENTS FOR MEMBERSHIP:
CSHA By-laws state: Active members shall be persons who hold a graduate degree with major emphasis in speech-language pathology, audiology, or speech-language or hearing science as described in the standing rules; or a graduate degree and present evidence of active research, interest and performance in the field of human communication. Associate members shall be persons qualified in a related profession who are members in good standing of said profession and who subscribe to the purpose of this Association. Student members shall be persons actively pursuing college or university training in speech and language pathology, audiology, or speech and hearing sciences and who do not qualify for active membership. Paraprofessional members shall be persons who have met the academic and supervised training requirements set forth by the Speech-Language Pathology and Audiology Board (SLPAB) and have been registered by the Board as speech-language pathology assistants. Active members shall have all privileges of the Association. Associate, student and paraprofessional (SLPAs) members shall have all privileges of the Association except voting and holding office.
DUTIES AND RESPONSIBILITIES OF MEMBERS:
Members shall:
  1. agree to abide by the Code of Ethics;
  2. participate in continuing education;
  3. responsible for communicating unique concerns and interests to the Board of Directors;
  4. speak as a representative of the Association only when serving in an official capacity with approval of the CSHA President and/or Board of Directors.
CSHA MEMBERSHIP RUNS FROM JANUARY 1 TO DECEMBER 31
(Individuals who join after September 1 will have membership privileges for the remainder of that calendar year and for the twelve months of the following calendar year.) The late date for payment of dues is a postmark date of January 2. If dues payment is not postmarked by January 2, a late fee of $25 will be imposed.
 
Promotional Code:
 
** You will be listed according to your chosen preferences on the Payment Form for both the Online Directory and the Printed Directory. You are unable to choose different listings for the directories. Please make sure to choose your preferences above. You may choose not to be listed in the Online Directory or Printed Directory. Only your name will be listed. This will allow you to have access to the Online Directory.
Note the following: CSHA sells label and contact lists based on the materials for which the consumer will be using them for. Workshop information is sent to everyone regardless of their listing preferences. Any other materials are sent only to those who have chosen to list their address in the directories. However, those materials must first be approved by CSHA.
Only CSHA approved materials will be mailed to CSHA member listings. Additionally, we cannot guarantee your contact information will or will not be listed online or printed. Please make sure to include your contact updates & listing preference(s) when submitting your dues payment.

 

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