CSHA STUDENT MEMBERSHIP APPLICATION

STUDENT MEMBERSHIP APPLICATION MAY NOT BE SUBMITTED ONLINE.  Program Chair Signature required.  Please fill out, print, obtain the required signature and submit to the address below.

 

Fields marked with * are required

*Last Name: *First: 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:

  Hm Phone:

Wk Phone:

Fax:

  E-mail Address:

 

Preferred Contact Listing in Directory: (Please check all that apply)

Home Phone Work Phone Fax E-mail All None

 

Membership Type: Student     Paraprofessional

*Student MUST have this application signed to qualify as a student affiliate
STUDENTS MUST COMPLETE
*Check: Part-Time Full-Time Undergrad Masters

*University Name:                   

*Month/Year of Graduation:   
*Program Chair Signature:    

 

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: 

 

Certification and Licensure:  Check A, B, G, & H ONLY if completed.

A. CCC Audiology

B. CCC Speech Pathology

C. Lang., Speech, & Hrng Specialist Credential

D. Teacher Hearing Impaired Credential

E. Educational Audiologist Credential

F. Administrative Services Credential

G. Audiologist

H. License in Speech-Language Pathology

I.  Bilingual Cross-Cultural, Lang & Academic Cert.

J. Specialty Certification:

K. Hearing Aid Dispenser's License

Circle ONLY if in progress:

L. CFY in Audiology

M. RPE in Audiology

N. CFY in Speech Pathology

O. RPE in Speech Pathology

 

Academic, highest degree held:

B.A.

B.S.

M.A.

M.S.

M.Ed.

Ph.D.

Ed.D.

Other:

 

California License:

Speech Pathology #:

Audiology #:

Expiration Date:

Expiration Date:

 

Areas of Interest for Selective Mailings:

Please designate 1st and 2nd interest with 1 and 2 respectively.

A. Audiology, Education and Habilitation of Hearing Impaired

B. Education & Habilitation of Children with Severe Lang. Disorders

C. Private Private

D. Professional Preparation (includes master supervisors of CFYs & RPEs

E. Speech, Language and Hearing Services in Medical Rehabilitation Centers, and Community Agencies

F. Language, Speech and Hearing Services in the Schools

G. Community Colleges


THE FOLLOWING INFORMATION WILL NOT BE INCLUDED IN ANY DIRECTORIES; HOWEVER, IT IS MAINTAINED IN THE CSHA ADMINISTRATIVE OFFICE.
Sex:  Male Female
Age Group: 20-29 30-39 40-49 50-65 65+
 
Primary Employment (more than 50% time): Secondary Employment (less than 50% time):

A. Schools, Public (Avg. caseload = #dup:  #undup:)

B. Schools, Non-Public

C. Private Practice

D. Academic, College/University

E. Clinic, Medically Based

F. Clinic, College/University Based

G. Community Agency or Clinic

A. Schools, Public

B. Schools, Non-Public

C. Private Practice

D. Academic, College/University

E. Clinic, Medically Based

F. Clinic, College/University Based

G. Community Agency or Clinic

 

 
Membership in other organizations: (check)

ASHA     

CEC     

ACSA     

CTA    

CRA 

CAA     

AAA     

NSSLHA     

OTHER:

 
Members and students please answer the following questions:  (check)

1. Specialty:

Speech-Language Pathology

Audiology

Both

2. Do you work with children ages:

0-3 years

3-5 years

5-17 years

 
Foreign Language Register:

Due to the population of non-English speaking (NES) and limited English speaking (LES) children and adults in California, CSHA is attempting to provide information relative to the availability of services.  This information will be available on request from the Administrative Office.  Please register only if you will provide clinical services in the language checked.

 

Cantonese 

French 

German 

Hebrew  

Italian

Korean 

Mandarin

SEE Language

Sign Language

Spanish

Tagalog

Vietnamese

Yiddish

Other

Bilingual Professionals:  By listing my name in the CSHA Foreign Language Directory, I agree to the definition of a bilingual professional as described. 

Signature of Agreement: 

 

Internet Directory

CSHA has the Membership Directory on CSHA's website.  The directory will be available only to CSHA members.  Security measures will include SSL (Secure Socket Layer) connection with the member's Username and ID for entrance.  Members who do not wish to be included in the Internet Directory, please check the box below:

No, do not include me in the Internet Directory.  Note:  Due to programming restrictions, checking this button will exclude the member from having access to the Internet Directory.


REQUIREMENTS FOR MEMBERSHIP:

CSHA By-laws state: Active members shall be persons who hold a mater's degree or equivalent* in speech and language pathology, audiology, or speech and hearing sciences.  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.  Active members shall have all privileges of the Association.  Associate and student members shall have all privileges of the Association except voting and holding office.

  

*CSHA Special Rules define equivalency as:

  1. A California school credential as a speech and language specialist (i.e.) Clinical Rehabilitation Services Credential; OR 

  2. A California license in speech-language pathology and/or audiology; OR

  3. Certificate of Clinical Competence in speech-language pathology or audiology

 

DUTIES AND RESPONSIBLY OF MEMBERS:

Members shall:    1. Agree to abide by the Code of Ethics; 2. participate in continuing education; 3. be 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.

 

MEMBERSHIP YEAR

RUN FROM JANUARY 1 TO DECEMBER 31.  (Individuals who join after September 1 will have membership privileges for the remainder of that calendar year and the twelve months of the following calendar year.)

 

PAYMENT BY CREDIT CARD
 
Charge my: MasterCard Visa

$  25 Student Membership

$  25 Paraprofessional Membership 

*Total Charged Amount:
*Account #:
*Exp. Date:
*Authorized User:  

By submitting this form, you are authorizing CSHA to process payment on the above credit card account.

 

 

QUESTIONS/COMMENTS

 

Fill out, print and fax/mail

 

CALIFORNIA 
SPEECH-LANGUAGE-HEARING ASSOCIATION

Attention: Membership Application
825 University Avenue
Sacramento, California 95825
PHONE: (916) 921-1568 or FAX (916) 921-0127

stacey@csha.org