NSSLHA Chapter Recertification Form

Local chapters are required to recertify with the national office annually to maintain affiliation with the national association.

Guidelines for Recertification

Chapters must recertify by October 31 or anytime there is a change in the chapter advisor or officers.
The chapter advisor must have current membership in ASHA.
The chapter officers must have national membership in NSSLHA.
A copy of the chapter's bylaws must be on file with the national office. (If the national office already has a copy of your bylaws, you only need to submit a copy if there are revisions). Chapters may e-mail a copy of their by-laws to nsslhaprograms@asha.org.

More information about maintaining an active NSSLHA chapter is available.

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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?*
Chapter 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 Contact Information
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:
Co-Advisor Years of Service:
Chapter Officers Contact Information
Chapter President First Name:*
Chapter President Last Name:*
NSSLHA Account Number:
Chapter President E-mail:*
Chapter President 1^st Day of Office:
Chapter Vice-President First Name:*
Chapter Vice-President Last Name:*
NSSLHA Account Number:
Chapter Vice-President E-mail:*
Chapter Vice-President 1^st Day of Office:
Other Officer First Name:
Other Officer Last Name:
NSSLHA Account Number:
Other Officer E-mail:
Other Officer 1^st Day of Office:
Other Officer First Name:
Other Officer Last Name:
NSSLHA Account Number:
Other Officer E-mail:
Other Officer 1st Day of Office:
Campus Affiliation Information
Is your local NSSLHA chapter required to register with your college or university?*
Yes No
How is your local NSSLHA chapter recognized by your college or university?*
Extracurricular Organizations (i.e. primarily student-led and sponsored - sororities and fraternities are examples of extracurricular organizations) Co-Curricular Organizations (i.e. directly associated with or sponsored by University academic departments or programs - honor societies are examples of a co-curricular organization) Co-Institutional Organizations (i.e. directly sponsored by a University administrative department or other administrative unit - the sponsoring department(s) or administrative unit(s) may dictate criteria and selection for membership) None of the Above
Does your college or university require the following to register/recognize your local NSSLHA Chapter?
A Full-Time Faculty/Staff Advisor A Mission Statement and/or By-Laws A List of Proposed Activities A List of the Elected and/or Appointed Officers and/or a Job Description of Each Position The Procedures for Elections and/or Appointments and a Schedule of Elections The Procedure For the Collection of Dues A Statement for Amending the By-Laws Annual Renewal With the College/University The Signature of the Department Chair/Dean/Graduate Program Director Indicating His/Her Approval of the Proposed Organization (if the chapter is recognized as co-curricular) The Signature of the Senior Administrator of the Sponsoring Department or Administrative Unit Indicating His/Her Approval of the Organization's Constitution (if the chapter is recognized as co-institutional) A Requirement That Membership and Participation is Open to All Full and Part-Time Students of the Particular Division/Graduate Program and Will Not Be Denied Based on Race, Religion, National Origin, or Physical Handicap
What rights/privileges does your college or university give to your local NSSLHA chapter?
Assistance with Recruiting New Members Use of Campus Facilities for Meetings or Programs Eligibility for Program Funding From the College/University (or department) Use of a Campus Mailbox Use of the College or University's Name Use of the College/Universities Federal Tax-Identification Number Liability Insurance Coverage for Events and/or Officers Leadership Development Training Assistance with 501c3 Applications and Annual Filings A Campus Supported Internet Site Participation in Campus-Wide Programs if Permission is Granted By the Sponsoring Organization or Office A Financial Account in the Bursar's Office (the organization will be required to adhere to any policies established for the management of financial accounts)

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NSSLHA Chapter Recertification Form

Guidelines for Recertification

Chapter Details

Chapter Contact Information

Chapter Advisor Contact Information

Chapter Officers Contact Information

Campus Affiliation Information