OSLHA 2011/2012 Membership Form

To join OSLHA or to renew your current membership for the 2011/12 FY, complete the Membership Form below.

Click to view the Membership Benefits, Categories, 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 but rates are not prorated so renew early to benefit from a full year of membership opportunities and insights.

Visit the Paper Application Form if you would like a printable application form to complete and mail.

Last 4 digits of Social Security Number:  
Last Name: First Name: Middle Initial:   
HOME Address:
City:    State:    Zip-Plus4 -
County:
E-Mail:
Employment Information
Employer: 
WORK Address:  
City:       State:             Zip-Plus4 -
Home Phone: - -            Work Phone: - -                       Fax:    - -  
Send OSLHA Mailings to:       HOME          WORK
Professional Focuses
Field:    Speech-Language Pathology       Audiology        SLP/Aud
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.                                                                   
Number of Years in the Profession: 
Member of:          ASHA   ASHA Member #       AAA AAA Member #
Membership Type

MEMBERSHIP CLASSIFICATION:  Choose ONE    (Begins July 1, expires June 30, 2012)

Associate Membership:
     5 - Consumer   (person using Aud/SLP services) -  $21.00
     6 - Student  -  $20.00
     7 - PEY/CF (Clinical Fellow)- $20.00
     8 - Allied Professional  - $45.00        (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-Language 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* (Can Not Have Held Membership Previously)  -  $60.00
     11/12 - Renewal Active Member*  -  $70.00
     16 - Life Member  -  $00.00   (As Approved by Legislative Council)

Honorary Membership: 
    15 - Honorary Membership Recipient (In Possession of Certificate for Membership)
Insurance Type - Optional

LIABILITY INSURANCE:   Choose ONE - (Active Members Only)   (Begins July 1, expires June 30, 2012)
$1,000,000 each claim / $3,000,000 fiscal year aggregate.
     1 - Employee  -  $45.00
     2 - Part-Time Private Practice  -  $45.00
     3 - Employee & Part-Time Private Practice -  $57.00
     4 - Student  -  45.00
    
Additional Options
Membership Certificate (Suitable for Framing)     $ 8.00
I would like to donate $20 to Sponsor a Student's Membership
Scholarship Fund Donation.  In Honor of Memory of:
    Amount  of Donation: $
Additional Preferences

I DO NOT want my name included on a MAILING LIST to receive speech and hearing related material

I DO NOT want to be included in OSLHA's Membership Directory (Includes names, addresses, phone numbers of OSLHA Members for use only by other OSLHA Members)

I DO NOT have access to the internet or email

List Convention Topic suggestions:

Additional Notes/Comments:
E-Mail Confirmation
Confirm E-Mail: A value is required.Invalid format.*Required Field
Total Due

*If this membership form is submitted by JUNE 30, 2011  AND  you are in Active Membership categories 9/10 or 11/12 above,  you are eligible for a $5 early renewal discount.  The discount will be automatically reflected in the total amount due.

TOTAL AMOUNT DUE:    $
    
Referral Credit
Referred for Membership By:
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 2011-2012 dues is 33%.  The nondeductible amount (33%) is calculated by dividing total OSLHA lobbying expenditures by total dues income (excluding all other income)

  

Click "Continue" to submit your Membership Application to the OSLHA Business Office and to proceed to payment, if applicable. If you are an honorary or life member recipient and no payment is due please click "Continue" to submit your form and then feel free to close out of the payment screen.

Membership/Insurance will be effective beginning July 1st or on the date of payment thereafter.

Please Note: Per Paypal policies, If you choose to pay with a credit card, you can not use a card that has been used to create a Paypal account without logging in to your Paypal account when prompted

Return to Home Page

View Our Refund Policy

Contact Us