MEMBERSHIP FORM
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To join OCSLHA print this form and mail it to the address below with your check. |
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NAME__________________________________________ DATE______________ |
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STREET___________________________________________________________ |
CITY/ZIP_______________________________________PHONE______________ |
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SCHOOL DISTRICT__________________________________________________ |
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EMAIL ADDRESS___________________________________________________ |
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How many years have you practiced? ____ |
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Speech/Language Pathology?_____ Audiology?_____ Other?_________ |
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How many years have you worked in Oakland County?________ |
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What population do you service? Early Intervention______ Preschool________ |
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Elementary____ Middle School_____ High School_____ Other_____________ |
| Are you ASHA certified? | Yes_____ | No_____ |
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MEMBERSHIP DUES: $25.00 GRAD STUDENT DUES:
$10.00 |
MAIL TO: Kelly Warrick, 7037 Magnolia Lane, Waterford, MI 48327
| Fill out the form below if you would like to be included in our Private Therapy list on our web site www.OCSLHA.com: | |
| Name: | District: |
| City of residence: | |
| In what areas are
you willing to work? . |
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| Specialty (age level & types of
impairments): . |
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| Available summers only? All year? | |
| How would you like to be contacted: Email address: Phone: |
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