CSHA Paraprofessional Membership Application

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:

Directory Listings - Click for more information

Please check all listing preferences that apply in the appropriate boxes below:

	DO NOT list my contact information in either directories.
	Please list me in both directories with the following contact information:
	All Contact Information
	Address
	Home Phone
	Work Phone
	Fax
	Email

Place of Employment:

Academic, highest degree held:

A.A.

B.A.

B.S.

Other:

California License:

SLP Assistant #:

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
H. Medical Center

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
H. Medical Center

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:


MEMBERSHIP REQUIREMENTS : Paraprofessional members shall be persons who have met the academic and supervised training requirements set forth by the Speech-Language Pathology and Audiology Board (SLPAB) and have been registered by the Board as speech-language pathology assistants. Active members shall have all privileges of the Association. Associate, student and paraprofessional (SLPAs) members shall have all privileges of the Association except voting and holding office.

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: Visa MasterCard

$45 Paraprofessional Membership Fee

*Total Charged Amount:

*Account #:

*Exp. Date:

*Authorized User:

My Ambassador Sponsor is:

QUESTIONS/COMMENTS

If paying by check, please mail this form along with payment to:

CALIFORNIA SPEECH-LANGUAGE-HEARING ASSOCIATION

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

katrena@csha.org