OSLHA 2010/2011 Membership Form

To join OSLHA, or to renew your membership, 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 fees are not prorated so renew early to benefit from a full year of membership opportunities.

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

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 be taken to the payment options page. If you are unsure if your application was received, please contact us at: oslhaoffice@donet.com

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 -
County that you Reside in:
Home Phone: - -            Work Phone: - -
Fax Phone:    - -             

E-Mail:   (Very Important - For Internal Use ONLY)

Confirm E-Mail:

 
Send OSLHA Mailings to:       HOME          WORK
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 #

 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.

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, which includes names, addresses, phone numbers, etc...of OSLHA Members for use by OSLHA Members.

I DO Prefer to access my Communication Matters Newsletter online-Do NOT Send a paper copy to me by mail.

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, 2011)
   Associate Membership:
     5 - Consumer   (person using Aud/SLP services) -  $21.00
     6 - Student  -  $20.00
     7 - PEY/CF - $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 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  -  $70.00
     *  11/12 - Renewal Active Member  -  $70.00
     16 - Life Member  -  $00.00   (Approved by Legislative Council)
    
LIABILITY INSURANCE:   Choose ONE - Optional  (Members Only)   (begins July 1, expires June 30, 2011)
     $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  -  45.00
    
Membership Certificate (Suitable for Framing)     $ 5.00
Scholarship Fund Donation.In Honor or Memory of
    Amount  of Donation: $
I would like to donate $20 to Sponsor a Student's Membership

If this membership form is submitted by JUNE 30, 2010  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:    $  (Please Change Your Total to Reflect Honorary Membership, as needed) 
    
 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 2010-2011 dues is 29%.  The nondeductible amount (30%) is calculated by dividing total OSLHA lobbying expenditures by total dues income (excluding all other income)

  

Click "Continue" to submit your Membership Application and payment to the OSLHA Business Office. Membership/Insurance will be effective July 1st or as received thereafter during the Fiscal Year. If you are an honorary or life member recipient and no payment is due please click "Continue" and close out of the payment screen.

Please Note: If you choose to pay with a credit card, you can not use a card in any way associated with a Paypal account without logging in to Paypal when prompted.

Return to Home Page