COLORADO SPEECH-LANGUAGE HEARING ASSOCIATION

2010 MEMBERSHIP APPLICATION FORM (INTERNET)
(Annual dues apply to year beginning March 1st 2010 and ending February 28th 2011)

To apply to join or renew your membership to the Colorado Speech-Language Hearing Association please 1) fill in the information requested on the form, 2) Print the page by clicking on the button below, and 3) mail it, together with a check for your membership fee to:

 CSHA
P. O. Box 345, Sedalia, CO 80135
or Fax: (720) 733-9044
Name:
Group Name: (for Challenge)
Organization:
Mailing Address:
City:   State:
County:   Zip Code:
Work Phone:   Home Phone:
FAX:
E-Mail:
Field :
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The following information is required from student members, Regular Members who are doctoral students, and Associate Members enrolled in a master's program:
University Attending:
________________________________________________
Signature of Program Chair/Designee
ASHA Member? Yes  No   
ASHA Certification: CCC-SLP  CCC-A   Both (SA)  
CO Dept of Education License: Yes  No     Please indicate type:
Highest Degree:   If other, please specify:
Granting University:    
Degree In: If other:
Work Setting: If other:
Employer: Title:
Do you provide Clinical Fellowship Supervision? Yes  No
Will your work setting provide Internship Supervision? Yes   No
Are you a Bi- or Multi-lingual Service Provider? Yes  No   
If "Yes", what language(s)?
Type of Membership (please see descriptions)

Cost
Special GROUP Challenge Rate (details) $60.00  
Regular (RE) $75.00
Regular (RE) (Full time doctoral student) $55.00
2 Year Membership (2Y) $120.00
Group (GR) Membership with 6 other members (must
     all be mailed together		 $60.00
Student (ST) $30.00
Life (LI) none

Please type in amount remitted with this application:

 $
CSHA Area:
Would you like to serve on a committee?  Yes  No
Willing to be a Speaker? Yes  No     Topic:
CSHA's Membership Directory will be posted on our web site for CSHA Members use only. Access will be password protected. Would you like to be included in the Directory?
Yes  No                            Click HERE to download the Directory Form (PDF)
Have you ever been a CSHA member? Yes  No     
If yes, have you gone by other names?
Referred to CSHA by: 

I verify that the information above is true and correct.
I have read and agree to abide by the CSHA Code of Ethics.

________________________________________________
Signature     (Required to process application)
 OFFICE USE:  Mem Type _____  Date Paid __________ Check # _______ Amt Pd. $_________ Posted ____ Card Issued ____ Packet Sent ____

Thank you for your new/renewal CSHA membership application!

If you need additional information or don't have access to a printer, please call
(720) 733-9044 or e-mail cshassoc@aol.com and we'll send you a membership package.

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