NSSLHA Chapter Recognition Program Form

Contact Information

Relationship to Chapter:

First Name:*

Last Name:*

Account Number:

E-mail:*

Region (locate your region):*

Chapter Name:*

Chapter Web Address:

Chapter Recognition Requirements Checklist

Has the chapter submitted a Chapter Recertification Form to the national office?*

Has the chapter participated in a CSD Career Awareness activity?*

Date of CSD Career Awareness Event (MM/DD/YYYY):

Has the chapter made a donation to the NSSLHA Loves campaign?*

Date of Donation (MM/DD/YYYY):

Amount Donated:

Has the chapter submitted any applications for the NSSLHA Grant Program?*

Which NSSLHA grants?

Has the chapter nominated an individual or organization for NSSLHA Honors?*

Which NSSLHA honor?

Has the chapter participated in CSD advocacy activities?*

Which activities (please describe and include dates or paste examples of letters sent, etc.)?

Has the chapter (or a representative of the chapter) been published in the Regional News & Notes, local newspaper, State Association News, The ASHA Leader, etc.?*

Please provide the publication name and/or the issue number.

Has the chapter contributed content to any of the national office social media sites?*

Which social media networks?

If other, please specify.

Does the chapter have any social media pages (e.g. Facebook, MySpace, etc.)?*

Please provide links to the chapter's social media networks.

Is there any additional information about the chapter you think the national office should consider?