Chapter Details
|
Region Number (locate your region):*
|
|
Chapter Category:*
|
|
Number of Students Enrolled in Audiology and/or Speech Program:*
|
|
How many students are local members of your NSSLHA chapter?*
|
|
Number of Students in Local Chapter with National Membership:*
|
|
What month/year does this chapter hold officer elections (MM/YYYY)?*
|
|
Date of First Membership Meeting in Fall Semester (MM/DD/YYYY):
|
|
Date of First Membership Meeting in Spring Semester (MM/DD/YYYY):
|
|
How often do you host local chapter meetings?*
|
|
Contact Information
|
Chapter Name:*
|
|
Chapter Mailing Address:*
|
|
Chapter City:*
|
|
Chapter State:*
|
|
Chapter Zip Code:*
|
|
Office Phone Number:*
|
|
Office Fax:
|
|
Primary Chapter Contact E-mail:*
|
|
Web Address:
|
|
Chapter Advisor First Name:*
|
|
Chapter Advisor Last Name:*
|
|
Chapter Advisor ASHA Account Number:
|
|
Chapter Advisor E-mail:*
|
|
Chapter Advisor Years of Service:*
|
|
Co-Advisor First Name:
|
|
Co-Advisor Last Name:
|
|
Co-Advisor ASHA Account Number:
|
|
Co-Advisor E-mail:
|
|
Chapter President First Name:*
|
|
Chapter President Last Name:*
|
|
Chapter President NSSLHA Account Number:
|
|
Chapter President E-mail:*
|
|
Chapter President Term:
|
|
Chapter Vice-President First Name:*
|
|
Chapter Vice-President Last Name:*
|
|
Chapter Vice-President NSSLHA Account Number:
|
|
Chapter Vice-President E-mail:*
|
|
Chapter Vice-President Term:
|
|
Other Officer First Name:
|
|
Other Officer Last Name:
|
|
Other Officer NSSLHA Account Number:
|
|
Other Officer E-mail:
|
|
Other Officer Term:
|
|
Other Officer First Name:
|
|
Other Officer Last Name:
|
|
Other Officer NSSLHA Account Number:
|
|
Other Officer E-mail:
|
|
Other Officer Term:
|
|
Other Information (if chapter has officers representing SLP/SLS and A/HS/Deaf or use to list all officers):
|
|
Additional Information:
|
|
|
|