Membership Form

NAME

FIRST NAME:
LAST NAME:

PREFERRED MAILING ADDRESS

STREET:
CITY:
STATE:
ZIP:

PHONE/EMAIL

HOME PHONE:
WORK PHONE:
EMAIL:

CERTIFICATION

Aud
SLP
Dual
Other

TYPE OF MEMBERSHIP

Regular (holds masters degree or equivalent): $40.00
Associate (holds bachelor degree or equivalent): $40.00
Two Year Membership (Regular or Associate): $60.00
Student (Requires verification letter from Department Head): $10.00
Life Member (USHA member for 10 years and over 65 years of age): Fee Waived
Two for One ($50 please list new member name):

Were you a USHA member July 2005 - June 2006 Yes No

EMPLOYMENT

EMPLOYER:
POSITION:

EDUCATION

YEAR:
UNIVERSITY:
 
CHECK ALL THAT APPLY
DEGREE: Bachelors
Masters
Doctorate
Other
 
UTAH STATE
LICENSE:		 AUD
SLP
Other
 
ASHA: Member
CCC-SLP
CCC-A
 
AAA
MEMBER:		 YES NO
 
SCHOOL
LICENSE:		 YES NO

USHA VOLUNTEER

Would you be willing to volunteer on a USHA committee? (If so, please indicate your interests)
Professional Matters   
Public Relations
Membership		 Publications
Program
Long Range Planning   		 Legislative Matters
Nominations
Professional Development

STUDENT VERIFICATION

For those applying for a student membership, please download the Student Verifcation Form and return it with your application fee.

OATH

I hereby apply for membership in the Utah Speech-Language-Hearing Association, and agree to abide by the By-Laws of the Association and its Code of Ethics.

Yes No     I agree to have my application information published on the USHA website.
Yes No     I agree not to divulge my USHA website password.
Yes No     I want to receive information from companies that provide information related to my professional practice.