Last 4
digits of Social
Security Number:
Last Name: First Name:
Middle Initial:
HOME
Address:
City:
County:
E-Mail:
Employment Information
Employer:
WORK
Address:
City:
Home Phone:
Fax:
Send OSLHA
Mailings to:
Professional Focuses
Field:
Professional
Practice Area:
Choose One: Audiology Schools Health Care Private Practice
Developmental Disabilities (formally I&DD)
Non-Profit Agencies University and Student Affairs Supervision
Position:
Choose One:
Speech-Language Pathologist
Speech-Language Pathology Supervisor
Administrator-Speech & Hearing Program
Audiology Supervisor
Audiologist
Full-time Student Bachelors Program
Full-time Student Master's Program
Full-time Doctoral Student
Consumer
Unemployed
Other
Choose One Baldwin Wallace College
Bowling Green State Univ.
Case Western Reserve Univ.
Cleveland State Univ.
College of Wooster
Kent State Univ.
Miami Univ.
Ohio State Univ.
Ohio Univ.
Univ. of Akron
Univ. of Cincinnati
Univ. of Toledo
Primary
Worksetting:
Choose One: 1 - Schools
2 - Community Center/Clinic/Hearing & Speech Center
3 - Hospital / Outpatient Center 4 - Rehabilitation Center 5 - ICFMR / MR/DD Facility 6 - Medical Office / ENT Office 7 - Early Intervention 8 - Workshop 9 - University 10 - Private Practice 11 - Home Health Agency 12 - Long Term Care Facility 13 - Multidisciplinary Center 14 - Government Agency
15 - Industry (hearing aid mfgrs, industrial testing, publisher, etc.)
16 - Other
Secondary
Worksetting (if applicable) :
Choose One: 1 - Schools 2 - Community Center/Clinic/Hearing & Speech Center 3 - Hospital / Outpatient Center 4 - Rehabilitation Center 5 - ICFMR / MR/DD Facility 6 - Medical Office / ENT Office 7 - Early Intervention 8 - Workshop 9 - University 10 - Private Practice 11 - Home Health Agency 12 - Long Term Care Facility 13 - Multidisciplinary Center 14 - Government Agency 15 - Industry (hearing aid mfgrs, industrial
testing, publisher, etc) 16 - Other
Certifications:
Check all that apply:
Highest
Degree: Choose One:
Number of
Years in the Profession:
Member of:
ASHA Member #
Membership Type
MEMBERSHIP
CLASSIFICATION: Choose ONE (Begins
July 1, expires June 30,
2014)
Active
Membership: Must meet ONE requirement below:-
Masters, SLP and/or equivalent title in major field or study, OR
Associate
Membership :
Honorary Membership:
Insurance Type - Optional
LIABILITY
INSURANCE: Consumer and Allied Members are Not Eligible for Insurance (Begins
July 1, expires June 30,
2014) $1,000,000 each claim / $3,000,000 fiscal
year aggregate.
Additional Options
Membership Certificate (Suitable for Framing)
$ 8.00
I would like to donate $20 to Sponsor a Student's Membership for one year
Scholarship Fund Donation In
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, 2013 AND The discount
will be automatically reflected in your total amount due.
Early Discount
TOTAL
AMOUNT DUE: $
Redeem Your Earned Recruitment Credit
Enter Your Redemption Code for Recruitment Credit you Acquired during the 2012/13 Year
Give Referral Credit to Your Recruiter
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 2013 -2014 dues is 44 %. The nondeductible amount (44 %) is calculated by dividing
total OSLHA lobbying expenditures by total dues income (excluding
all other income)
