OSLHA MEMBERSHIP FORM
2008 / 2009 Fiscal Year

 July 1, 2008 - June 30, 2009

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To join OSLHA, or to renew your membership, complete the Membership Form below. 
See Membership Benefits, Requirements, and Liability Insurance pages for additional information. 
The Membership & Liability Insurance Fiscal Year term runs from July 1 - June 30.   You may join anytime during the fiscal year.

TAB through form, Do NOT use the "Enter" key
Be sure to SUBMIT your application at the end of this form.  The application is not received if you press the "enter" key, even though you may receive the confirmation "Thank You" note.

The OSLHA office will send an
E-mail confirmation of receipt of your on-line Membership Application
(be sure to provide your E-Mail address below)
If you do not receive a confirmation of receipt of your on-line form within 5 working days of form submission, please contact the OSLHA office at:  oslhaoffice@donet.com   or   800-866-OSHA

Last 4 digits of Social Security Number:  
Last Name: First Name: Middle Initial:   
HOME address:
City:    State:    Zip-Plus4 -
Employer: 
WORK Address:  
City:       State:             Zip-Plus4 -
Home Phone: A/C -             Work Phone: A/C -
Fax Phone:    A/C -                

E-Mail:   Very Important - For Internal Use ONLY)
 
Send OSLHA Mailings to:       HOME          WORK
Field:    Speech-Language Pathology       Audiology        SLP/Aud
County that you Reside in: 
Professional Practice Area: 
Position:  
If Student: Attending University 
                  Graduation Year:  
Primary Worksetting: 
Secondary Worksetting (if applicable): 
Certifications:   Check all that apply:
CCC Speech Pathology
CCC Audiology
Ohio Educational License
Ohio Licensure, Speech Pathology
Ohio Licensure, Audiology
Licensure in another state      Specify State:
Highest Degree:  Choose One:
     Doctorate, Speech Pathology or Audiology:   Ph.D.   Au.D.    Ed.D.
     Doctorate, Other:                                                 Ph.D.   Ed.D.
     Master's, Speech Pathology or Audiology:     M.A.    M.S.     M.Ed.
     Master's, Other                                                    M.A.    M.S.     M.Ed.
     Bachelor's, Speech Pathology or Audiology   B.A.    B.S.
     Bachelor's, Other                                                B.A.    B.S.
     Other                                                                       
Number of Years in the Profession: 
Member of:          ASHA         AAA

 Election Ballot will be posted online.  You will be advised via email listserv and newsletter when to vote.  Be sure you provide your email address.

DO NOT mail HEARSAY journal.  I will access it on OSLHA's website

I DO NOT want to be included in OSLHA's Membership Directory which will include names, addresses, phone numbers, etc. of OSLHA members.

I DO NOT want my name included on a MAILING LIST to receive speech and hearing related material
List Convention Topic suggestions:
I have been a member of OSLHA for years.  (Approximate # of years)
 
MEMBERSHIP CLASSIFICATION:  Choose ONE    (begins July 1, expires June 30, 2009)
   Associate Membership:
     5 - Consumer   (person using Aud/SLP services) -  $21.00
     6 - Student  -  $15.00
     7 - PEY/CF - $15.00
     8 - Allied Professional  - $43.00        (PT, OT, etc) Specify:
   Active Membership:  Must meet ONE requirement below:
            - Masters, SLP and/or equivalent title in major field or study, OR
                - Active License as Speech Pathologist and/or Audiologist in Ohio, OR
                - Membership in the American Speech-Language-Hearing Association, OR
                - Grandfathered by OSLHA -January 1, 1984
     *  9/10 - New Active Member  -  $63.00
     *  11/12 - Renewal Active Member  -  $63.00
     16 - Life Member  -  $00.00   (Approved by Legislative Council)
    
LIABILITY INSURANCE:   Choose ONE - Optional  (Members Only)   (begins July 1, expires June 30, 2009)
     $1,000,000 each claim / $3,000,000 fiscal year aggregate.
       Insurance not available to Allied Professionals and Consumers.
     1 - Employee  -  $45.00
     2 - Part-Time Private Practice  -  $45.00
     3 - Employee & Part-Time Private Practice -  $57.00
     4 - Student  -  40.00
    
Membership Certificate (Suitable for Framing)     $ 5.00
Scholarship Fund Donation.  In Honor or Memory of
    Amount  of Donation: $
I would like donate $15 to Sponsor a Student's Membership
If this membership form is submitted by JUNE 30, 2008  AND  you are in Membership category *9/10, *11/12 above,  you are eligible for a $5 discount.  The discount will be reflected in the total amount due.

TOTAL AMOUNT DUE:    $    ( If calculation is not correct, type in correct amount due.)
    
PAYMENT TYPE:                     VISA           Mastercard
                            Bank Card #   (16 digits)
                            Expiration Date:    Month/Year
 Notes/Remarks:

Dues payment to OSLHA, a 501(c)6 organization, are not deductible as charitable contributions for federal income tax purposes.  However, they may be deductible under other provisions of the Internal Revenue Code subject to restrictions imposed as a result of lobbying activities.  In those situations where dues may be deductible, OSLHA estimates the nondeductible portion of your 2008-2009 dues is 29%.  The nondeductible amount (29%) is calculated by dividing total OSLHA lobbying expenditures by total dues income (excluding all other income)

  

Click "SUBMIT" to send Membership Application to OSLHA Business Office for processing.  Membership/Insurance will be effective upon receipt of payment.

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