Name: Mr. Mrs.Ms. Miss Dr.
Street Address: City: Zip Code:
Telephone (Home): Business:
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Can we send the newsletter via e-mail? Yes No
Primary employment setting: School Hospital Agency University/Lab Private Practice
Employer:
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Please Check all that apply:
Member of: ASHA CCC/SLP CCC-A NYSSLHA Other:
NYS Licensure: Speech Pathology Audiology
NYS Certification: Teacher of the Speech & Hearing Handicapped (TSHH) Other:
If a new member, who referred you to SHAWNY: _________________________
Please list any speakers or topics that you would be interested in for future workshops:
I approve of any/all of this information to be included in the next SHAWNY directory.
Include me on the private practice list. (Which may be given out to individuals requesting a speech or hearing professional in a certain area or that works with a certain population.)
Private practice members should include the following information:
Area(s) served:
Population/ages served:
Evaluation/Therapy type(s):
Print out completed application and send with a check made payable to SHAWNY to:
SHAWNY Membership Chair: Donna M. Ringholz, 267 McNaughton Ave. Cheektowaga, NY 14225
OFICE USE ONLY: Date rec'd: