Membership Form | OSSPEAC - Ohio Speech Pathology Educational Audiology Coalition

OSSPEAC Membership Form w/Conference Registration

Please use the form below to join OSSPEAC and take advantage of the "Member" rate for the OSSPEAC Conference. Please select "I would like to become a Member NOW!" option on the conference registration form and the $40.00 cost will be added to your conference registration. If you have any questions, please feel free to contact OSSPEAC at osspeac@windstream.net.

If you would like to write a check and pay your membership separate from the conference fees, please print out the membership form posted on the left side of this page and mail to OSSPEAC, 205 Glendale Street, LaGrange, Ohio 44050.

* = Required Information

Downloads

2010 OSSPEAC Membership Form

First Name: *
Last Name: *
Home Address: *
City: *
State: *
ZIP Code: *
Home/Cell Phone: *
Work Phone:
E-Mail Address: *
Work Site:
Work County:
State Support Team Region:
Position: *	01 Speech-Language Pathologist 02 Educational Audiologist 03 Speech-Language Supervisor 04 Audiologist Supervisor 05 Full-Time Student 06 Teacher 07 University Personnel 08 Unemployed 09 Retired 10 Other
Work Setting: *	01 Public Schools 02 State Support Team 03 Non-Public Schools 04 Community DD Program 05 State DD Institution 06 Private Practice 07 University 08 Other
Certification (check all that apply): *	01 Ohio Public School Certificate 02 Speech-Language-Ohio License 03 Audiologist-Ohio License 04 CCC Speech-Language 05 CCC Audiology 06 Other
Highest Degree: *	01 Bachelors, Speech-Language Pathology 02 Bachelors, Audiology 03 Bachelors, Other 04 Masters, Speech-Language Pathology 05 Masters, Audiology 06 Masters, Other 07 Doctorate, Speech-Language Pathology 08 Doctorate, Audiology 09 Doctorate, Other 10 Other
School Where Highest Degree was Granted: *	01 Ashland University 02 Baldwin-Wallace College 03 Bowling Green State University 04 Case Western Reserve University 05 Cleveland State University 06 Kent State University 07 Miami University 08 Ohio State University 09 Ohio University 10 University of Akron 11 University of Cincinnati 12 University of Dayton 13 University of Toledo 14 Wright State University 15 Other
Membership Classification/Cost:	01 Professional Membership - $40.00
I would like to volunteer to serve on the following committee:	Honors Legislation Memberhip Liaisons Nomination Program Publication Instruction
Include my name in the OSSPEAC Directory:	Yes No
My name can be given for the purpose of educational research:	Yes No