Louisiana Speech-Language-Hearing Association

 

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LSHA MEMBERSHIP FORM

Please complete, print and mail form with a check payable

 to LSHA at:
LSHA
8550 United Plaza Blvd.
Suite 1001
Baton Rouge, LA 70809

                                                                                     Date:

Name:

Home Address:

                               

City:                         State:

Zip:                        Phone: Work

Fax:                            Home

Employer:

Title:

Work Address:

                            

City:                         State:

Zip:                       E-mail:

LA License #            Type:SLPAUDDUAL

ASHA Certification Type:SLPAUDDUAL         

Highest Degree Awarded:                       Year:

University/College Attended(ing)

La. House Dist. # or Rep.'s Name

La. Senate Dist. # or Sen.'s Name

*For help locating your Senator or Representative CLICK HERE

Please check appropriate category:

Full Member: $45, Persons who have a master's degree or equivalent in Speech-Language Pathology and/or Audiology

Full Member/First-Year Graduate: Free, Persons who have just completed a Master's degree program. New graduates receive complimentary membership for the remainder of the calendar year for May and August graduates and for the following calendar year for December graduates.                              Graduation Date

Associate Member: $30, Persons who are employed in and/or present evidence of interest in the field of communication disorders and/or sciences but do not meet the requirements of a Full Member or Student Member

Student Members: $20, Persons who present evidence of current full-time matriculation in a graduate or undergraduate program in speech-language pathology, audiology, or speech and hearing science, and who are not eligible for Full membership.

Voluntary LSHA PAC Contribution of (min. $5.00) $

Total enclosed

Dues payments to LSHA are not deductible as charitable donations for Federal income tax purposes. Federal law prohibits the deduction from your taxes that portion of member dues allocated to lobbying activities. LSHA estimated that 50% of your dues are not deductible under any provisions of the tax code.

LSHA.
Copyright 1999 [LSHA]. All rights reserved.
Revised: June 12, 2008

 

Contact US: LSHA; 8550 United Plaza Blvd.; Suite 1001; Baton Rouge, LA 70809; (225) 922-4512; Fax: (225) 922-4611; Email: lsha@pncpa.com