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Home
About Us
- Leadership
Events
Membership
Contact Us

Become a Member

Membership Form

Membership Form

Name(Required)

First Last

Pronouns

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email(Required)

Education, Employment & Professional Information

School you are currently enrolled in (if student):

Position (If applicable):

Employer (if applicable):

Highest Degree Earned(Required)

Associates Degree

Bachelor

Master

Doctoral

Check all that apply:

Work Setting:(Required)

School

Early Intervention

University/College

Hospital/Rehab/SNF

Fed/State Agency

Private Practice

Long-term care

ENT/Medical Practice

Retired

Other

Ages Served:(Required)

All ages

Newborn

Preschool

School age

Adult

Geriatric

N/A

Memberships & Certifications:(Required)

State license

ASHA

AAA

Teacher Certification

Au.D

SLP

SLP-A

Bilingual

HA dispenser

None

How long have you been a member of NBASLH?

New member!

1-3 Years

3-10 Years

10 years+

I am not currently a member of NBASLH

Please select the type of membership you are applying for:

Please select the type of membership you are applying for:(Required)

Voting Membership

Non-voting Membership

Institutional Membership (student)

Select Voting Membership

Professional Member

Early Professional Member

Student Member

Professional Membership
(donation recommended $50)
● Must be a member of NBASLH
● Will have full voting rights
● May serve on the BOD
● May serve as a chair of a committee

Early Professional Member
(donation recommended $35)
● Must be a member of NBASLH
● Must be in the first three years of their career
● Will have full voting rights
● May serve on the BOD
● May serve as a chair of a committee

Student Member
(donation recommended $10)
● Must be a member of NBASLH
● Will have student voting rights
● May serve on the BOD
● May serve as a chair of a committee

Voting Membership Certification(Required)

I certify that I am a current members of NBASLH

Select Non-voting Membership

Professional Participant

Early Professional Participant

Student Participant

Professional Participant
(donation recommended $50)
● Not a member of NBASLH
● Do not have voting rights
● May be a member of a committee
● May not chair a committee

Early Professional Participant
(donation recommended $35)
● Not a member of NBASLH
● Do not have voting rights
● Must be in the first three years of their career
● May be a member of a committee
● May not chair a committee

Student Participant
(donation recommended $10)
● Not a member of NBASLH)
● Do not have voting rights )
● May be a member of a committee)
● May not chair a committee

How did you hear about NEASLH?(Required)

Instagram

Facebook

Website

Email Promotion

Word of Mouth

Referral

Other

Want to Get More Involved with NEASLH?

No thanks, just joining for now.

Yes!

I would like to get involved by:

Joining a Committee

Donating
(Please select the donation option on the fee payment page or add your donation to the membership fee if you are mailing your payment)

Which Committee?

Membership

Public Relations

Programs

By-Laws

Student

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Have any questions?

Fill out the form below with any questions you have for the Northeast Alliance for Speech, Language and Hearing (NEASLH) organization

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The mission of Northeast Alliance for Speech, Language and Hearing is to maintain a viable mechanism through which the needs of Black professionals, students and individuals with communication disorders can be met.

northeastnbaslh@gmail.com

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