Fillable Application to Become an Assistant of the American (American Speech-Language-Hearing Association)

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Application to Become an Assistant of the American (American Speech-Language-Hearing Association)

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Application to Become an Assistant of the
American Speech-Language-Hearing Association
1| APPLICANT PROFILE
Title: q Miss q Mr. q Mrs. q Ms.
First Name _______________________________ Middle Name _________________________________________
Last Name _______________________________ Previous Name ________________________________________
Mailing Address _________________________________________________________________________________
City ____________________________________ State _____________________ Zip ______________________
Cell Phone #______________________________ Email ________________________________________________
Check one.
q I am applying as an Audiology Assistant.
q I am applying as a Speech-Language Pathology Assistant.
2| EMPLOYMENT PROFILE
NOTE: Though your state may use different terms, such as technician, aide, associate, or other title, the use of
“assistant” throughout this application is meant to include all titles of support personnel in audiology or speech-
language pathology.
Check one.
q I am employed as an audiology assistant or as a speech-language pathology assistant.
   Note: If you are employed, you must complete Section 5a.
q I am not currently employed as an audiology assistant or as a speech-language pathology assistant.
   Note: If you are not employed, you must complete Section 5b.
3| LICENSURE, REGISTRATION OR CERTIFICATION PROFILE
Check one.
q I am licensed, registered, or certified to work as an audiology assistant or as a speech-language pathology
assistant.
State issuing license, registration, or certificate: _____
License, registration, or certification number, if applicable: ______________________________
q I am not licensed, registered, or certified to work as an audiology assistant or as a speech-language pathology
assistant.
4| EDUCATION PROFILE
Check one.
q My education or training background meets the requirements of my state for audiology assistants or
speech-language pathology assistants.
q My state does not set education requirements for audiology assistants or speech-language pathology assistants.
Please complete:
 University/Institution: ______________________________________________
Degree Type:
q Associate’s degree Bachelors: q BA q BS Masters: q MA q MS
q High school diploma q Course or other relevant training
Degree Area:
q Communication Sciences & Disorders (CSD) q Audiology q SLPA q Speech-Language Pathology
q Other, please specify: ________________________________________________________________
Name of course or other relevant training: ______________________________________________
Degree Date (mm/dd/yy): ______________________________________________
5| REQUIRED SIGNATURE
5a| If you are employed as an audiology assistant or as a speech-language pathology assistant, you must obtain the
signature of the ASHA-certified professional who supervises your work.
NOTE TO SUPERVISING AUDIOLOGIST OR SPEECH-LANGUAGE PATHOLOGIST: By signing this application you
are verifying that you supervise this applicant in accordance with the Speech-Language Pathology Assistant Scope
of Practice or the Audiology Assistants Overview and that in your opinion, this applicant is qualified to perform the
assigned tasks of either an audiology assistant or a speech-language pathology assistant.
Signature of Supervising Audiologist or Speech-Language Pathologist Date
__________________________________________________________ _________________________
ASHA ID NUMBER: _______________
First Name: _______________________________ Last Name: _____________________________________
Employer: ________________________________________________________________________________
City: _______________________________________________ State/Province: _______________________
5b| If you are not employed as an audiology assistant or as a speech-language pathology assistant, you must
obtain the signature of the program director or instructor of your audiology or speech-language pathology training
or education program.
NOTE TO PROGRAM DIRECTOR OR INSTRUCTOR: By signing below, you are verifying that this applicant has received
the required training as an audiology assistant or speech-language pathology assistant, and this applicant is qualified
to perform either the assigned tasks of an audiology assistant or a speech-language pathology assistant.
Signature of Program Director Date
__________________________________________________________ _________________________
ASHA ID NUMBER: _______________
First Name: _______________________________ Last Name: _____________________________________
Employer: ________________________________________________________________________________
City: _______________________________________________ State/Province: _______________________
6| PLEASE VERIFY: AS AN ASHA ASSISTANT, I WILL AGREE TO:
• Perform my job solely within the appropriate scope of responsibilities described in the Speech-Language
Pathology Assistant Scope of Practice and the Audiology Assistants Overview.
• Perform only those tasks assigned by a supervising audiologist or speech-language pathologist.
• Work only under the supervision of an ASHA-certified audiologist or speech-language pathologist.
• Adhere to all applicable state (province) laws and rules regulating the professions listed above.
I, _____________________________________________ , have read and agree to the above. Further, I agree that the
information provided on this application is true and accurate.
____________________________________________
_____________________
Signature of Applicant Date
Payment Information
ASSISTANT MEMBERSHIP: JANUARY 1 – DECEMBER 31
METHOD OF PAYMENT
Payment by Check
q Fees enclosed ($75).
(Payment must be made in U.S. dollars. Make checks payable to ASHA. Payments are not refundable and must be
paid in full at the time of application.)
Payment By Credit Card
q Please charge $75 to my: q Visa  q MasterCard  q Discover
______________________________________ ________/______________
Credit Card Number Expiration Date (MM/YYYY)
_________________________________________________________________________
Signature
Mail your completed application and dues payment to:
American Speech-Language-Hearing Association
P.O. Box 1160 #210
Rockville, MD 20849
We cannot process incomplete applications. If you have questions about this application, contact the
ASHA Action Center at 800-498-2071 or actioncenter@asha.org.
Please DO NOT email any credit card payments.
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Application to Become an Assistant of the American (American Speech-Language-Hearing Association)

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Completed 27 August 2020

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