CSHA Professional Membership Update

Fields marked with * are required
*Last:  *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:

Home Phone:

Work Phone:

Fax:

Email 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

 

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

Check ONLY if in progress:

L. CFY in Audiology

M. RPE in Audiology

N. CFY in Speech Pathology

O. RPE in Speech Pathology
P. SLP-A

 

Academic, highest degree held:

B.A.

B.S.

M.A.

M.S.

M.Ed.

Ph.D.

Ed.D.
A.A.

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 Practice

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: 

 

 

*

 

Questions/Comments