OSLHA 2016/2017 Membership Form

To join OSLHA, or to renew your current membership for the 2016/17 FY, complete the Membership Form below.

Please contact us if you are looking for membership and/or insurance coverage for the remainder of our 2015/16 membership year!

Click to view the Membership Benefits, Categories, and Liability Insurance pages for additional information. The Membership & Liability Insurance Fiscal Year term runs from July 1 - June 30. You may join anytime during the fiscal year but fees are not prorated so renew early to benefit from a full year of membership opportunities.

Visit the Paper Application Form if you would like to print a blank form to complete and mail.

Last Name: First Name: Middle Initial:   
PREFERRED MAILING Address:
City:    State:    Zip-Plus4 -
County:
E-Mail:
Daytime Phone:( ) - -         Alternate Phone:( ) - -                        
Fax:   ( ) - -
 
Employment Information
Employer: 
Professional Focuses
Field:    Speech-Language Pathology       Audiology        SLP/Aud
Professional Practice Area: 
Position:  
If Student: Attending University 
                  Graduation Year:  
Primary Worksetting: 
Secondary Worksetting (if applicable)
Certifications:   Check all that apply:
CCC Speech Pathology
CCC Audiology
Ohio Educational License
Ohio Licensure, Speech Pathology
Ohio Licensure, Audiology
Licensure in another state      Specify State:
Highest Degree:  Choose One:
     Doctorate, Speech Pathology or Audiology:   Ph.D.   Au.D.    Ed.D.
     Doctorate, Other:                                                   Ph.D.   Ed.D.
     Master's, Speech Pathology or Audiology:     M.A.    M.S.     M.Ed.
     Master's, Other                                                      M.A.    M.S.     M.Ed.
     Bachelor's, Speech Pathology or Audiology   B.A.    B.S.
     Bachelor's, Other                                                  B.A.    B.S.                                                                   
Number of Years in the Profession: 
Member of:         
American Speech-Language-Hearing Association (ASHA)   ASHA Member #      
American Academy of Audiology (AAA)      AAA Member #
Membership Type

MEMBERSHIP CLASSIFICATION:  Choose ONE    (Begins July 1, expires June 30, 2017)

Full Memberships:  Must meet ONE requirement below:
          
- Masters, SLP and/or equivalent title in major field or study, OR
           - Active License as Speech-Language Pathologist and/or Audiologist in Ohio, OR
           - Membership in the American Speech-Language-Hearing Association, OR
           - Grandfathered by OSLHA -January 1, 1984

New Active Member* (can not have held membership previously) - $60.00
Renewal Active Member* - $70.00
Life Member (grandfathered - approved before July 1, 2012) - $0.00
Life Member (Approved after July 1, 2012) - $20.00

Associate Memberships:

Student - $20.00
Supervised Professional (Clinical Fellow) - $40.00
Allied Professional/Consumer -    $40.00

Honorary Membership: 


Honorary Membership Recipient or in Possession of a Certificate for a Free Year of Membership

 

 

Insurance Type - Optional

LIABILITY INSURANCE:   Consumer and Allied Members are Not Eligible for Insurance
We are pleased to announce increased coverage is now bring provided to our participants:
$2,000,000 each claim / $4,000,000 fiscal year aggregate
Choose ONE -   (Begins July 1, expires June 30, 2017)

Employee  -  $66.00
Part-Time Private Practice  -  $56.00
Full Time Private Practice  -  $106.00
Employee & Part-Time Private Practice -  $76.00
Student  - $51.00
None Needed At This Time  - $0.00
Additional Options
Membership Certificate (Suitable for Framing)     $ 8.00
Scholarship Fund Donation In Honor of Memory of:
    Amount  of Donation: $
Additional Preferences

I DO NOT want my name included on a MAILING LIST to receive speech and hearing related material

I DO NOT want to be included in OSLHA's Membership Directory (Includes names, addresses, phone numbers of OSLHA Members for use only by other OSLHA Members)

List Convention Topic suggestions:

Additional Notes/Comments:

E-Mail Confirmation
Confirm E-Mail: A value is required.Invalid format.*Required Field
Total Due

*If this membership form is submitted by JUNE 30, 2016  AND  you have selected a Full Renewal Membership Selection above,  you are eligible for a $5 Early Bird Renewal Discount.  The discount will be automatically reflected in your total amount due.

TOTAL AMOUNT DUE:    $
    

 Redeem Your Earned Recruitment Credit
Enter Your Redemption Code for Recruitment Credit you Acquired during the 2015/16 Year
 Give Referral Credit to Your Recruiter
Referred for Membership By:
Dues payment to OSLHA, a 501(c)6 organization, are not deductible as charitable contributions for federal income tax purposes.  However, they may be deductible under other provisions of the Internal Revenue Code subject to restrictions imposed as a result of lobbying activities.  In those situations where dues may be deductible, OSLHA estimates the nondeductible portion of your 2016-2017 dues is 29%.  The nondeductible amount (29%) is calculated by dividing total OSLHA lobbying expenditures by total dues income (excluding all other income)

  

Click "Continue" to submit your Membership Application to the OSLHA Business Office and to proceed to payment options.

*If you are an honorary or life member recipient and no payment is due please click "Continue" to submit your form and then feel free to close out of the payment screen.

Membership/Insurance will be effective July 1st or on the date of payment if purchased midyear.

Return to Home Page

View Our Refund Policy

Contact Us