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NSSLHA Member-at-Large Application Form

All Regions: Audiology Students Only

The deadline for Member-at-Large applications is April 18, 2012. Letters of recommendation and resumes must be received by April 25, 2012.

Application materials are not complete until all materials are received in the national office:

  • Completed application with Statement of Interest
  • Resume
  • Reference letters from one professional and one student

For more information, read the FAQs about the NSSLHA Executive Council.

* indicates required field.

Applicant Information

Applicant First Name:*

Applicant Last Name:*

NSSLHA Account Number:*

Are you a member of your local NSSLHA chapter?

Region (locate your region):*

Do you use social networking sites?*

If yes, which sites do you use?

Please include a page or blog name for any social networks you use or author.

 Facebook

Twitter

Digg

Blog

Other

Contact Information

Mailing Address (correspondence related will be sent to this address):

City:

State:

Zip Code:

Phone Number:*

Fax:

E-mail:*

Education

Applicants must be enrolled in school (undergraduate, graduate or a combination of both) for at least 3/4 of the 1 year term beginning on July 1, 2010. If an applicant has a question about their eligibility, they should contact NSSLHA at nsslhaprograms@asha.org. Only audiology majors will be selected for the member-at-large position.

I am currently enrolled in an undergraduate program.*

*If yes, I expect to receive my bachelor's degree (MM/YYYY):

Area:

*If other, please specify.

Name of University Awarding Bachelor's Degree:

I am currently enrolled in a graduate program.*

*If yes, I am in my:

I expect to receive my graduate degree (MM/YYYY):

University Awarding Degree (not applied or accepted, use "undecided"):

Area:

*If other, please specify.

Area of Professional Interest (e.g., pediatrics, swallowing, undecided):

Assurances

I understand that the Member-at-Large position is a voluntary position with a one-year term.*

I understand it is essential that the Member-at-Large attend two NSSLHA Executive Council meetings (one meeting occurs during the ASHA Convention in November; the other meeting is held in the spring at the national office in Rockville, Maryland), attend all American Speech-Language-Hearing Association (ASHA) Advisory Council meetings (dates to be determined), and maintain continual communication with the Advisory Council. Travel expenses will be provided by NSSLHA.*

I understand that if selected for the position I will allow the NSSLHA Executive Council to select an alternate for my position who will be responsible for completing my term should I not be able.*

Race/Ethnicity

One of NSSLHA's goals is to have its membership represent the multicultural diversity of American society.

Race/Ethnicity:

Tribal Affiliation (for American Indians - including Alaskan Natives):

Resume
You may cut and paste your resume from a Word document into this area or send your resume to nsslhaprograms@asha.org as a separate attachment. If you choose to send your resume via e-mail, please type "sending via e-mail" in the space below. If you are copying and pasting your resume below, please note that any formatting in Word will not transfer into the following box.*

Statement of Interest

Please provide the NSSLHA Executive Council with a statement that explains your interest in the position. Please answer all questions below and limit your responses to 500 words or less.

I joined NSSLHA because…*

I applied for a position on the NSSLHA Executive Council because…*

During my one-year term on the council, I will be successful if I accomplish…*

My vision for my term of service to NSSLHA and to the profession of audiology/speech-language pathology is…*

References

Please have one professional and one student provide references on your qualifications for this position. Please encourage them to send their reference letters electronically to nsslhaprograms@asha.org.

 

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