Wisconsin Speech-Language Pathology and Audiology Association

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WSHA-P
1360 Regent Street, #154
Madison, WI 53715
(800) 545-0640
FAX (888) 729-3489
wsha@wisha.org

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WSHA-P Membership Application

Mailing labels and on-line directory information are prepared based on the information supplied.
Personal Information:
First Name:
Last Name:

Home:
Address:

City:
State:
Zip Code:
Phone:
County of Residence:

Work Site:
Name of Facility/ School District:
Primary Location School/Department:
Address:

City:
State:
Zip Code:
Phone:
Fax:

Preferred Mailing Address:	Home Work
Deliver Communication Connection by:	E-Mail Mail
Check here if you want your mailing information omitted from labels sold for non-WSHA-P activities.
Email: (Please list only one address)

Membership Fee Information:

WSHA-P membership is from July 1 to June 30.
	Regular - $95.00 Persons with a graduate degree in speech-language pathology, audiology, speech, language, or hearing science, or education of the hearing impaired; or a graduate degree or its equivalent and evidence of research, interest, and performance in human communication.
	Associate - $90.00 Persons with an undergraduate degree, or a graduate degree in related professional disciplines, or with an interest in speech, hearing or language who do not qualify as Regular Members.
	Student Member - $25.00 Persons currently enrolled full-time in a college or university within the State of Wisconsin majoring in communicative disorders, speech-language pathology, audiology or related disciplines.
	Students please include school and department chair signature:

Membership Dues Amount:

I would also like to contribute to the following:

Student Member Sponsorship:

WSHA Foundation:
(Please include separate check made payable to the WSHA Foundation)

Total:

39% of WSHA-P dues for 2007-2008 cannot be deducted as a business expense for federal income tax purposes due to our lobbying activities. (This is not a PAC.)

Payment Information:

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Card No.	(please leave out dashes)
Exp. Date	/

1360 Regent Street, #154, Madison, WI 53715 | FAX (888) 729-3489 | (800) 545-0640 | wsha@wisha.org