WSUSSLHA membership application form

WSU Student Speech-Language-Hearing Association

(WSUSSLHA)
Applications must include payment of the annual membership fee in the amount of $20.00 (or $30.00 for 2 years, or $10 for one semester) for it to be processed.

Return completed form and payment to WSUSSLHA. Several options to do this:
1. Submit completed membership form. Then make payment (credit/debit card) via our WSUSSLHA online store.
2. Bring form and dues to Department of Communication Sciences and Disorders - 401 Ahlberg Hall or give to a WSUSSLHA officer.
3. Mail form and dues to: WSUSSLHA, Wichita State University, 1845 Fairmount, Wichita, KS 67260-0075.
Please make checks payable to WSUSSLHA. We also accept cash and money orders.
Name
WSU ID
Mailing and Contact Address:
Street
City
State/Country
Zip+4
Telephone
Please enter your telephone number.Format: (000) 000-0000.
E mail
example@example.com
Permanent Address (if different):
Street
City
State/Country
Zip+4
Academic Status:
Choose one:

FreshmenSophomoreJuniorSeniorGraduate student
What is your specialization:

Speech-Language PathologyAudiology
When do you expect to graduate?

MonthDayYear
Undergraduates: Are you interested in pursuing your studies in the CSD graduate program at WSU?

YesNo
Are you interested in volunteering on any WSUSSLHA committees?

YesNo
Are you interested in becoming an officer of WSUSSLHA?

YesNo
Are you a member of either of these professional organizations?

KSHANSSLHANeither one
Date

MonthDayYear
- FOR OFFICE USE ONLY:
  
  LIST DATE AND MARK PAYMENT METHOD, STATUS, ETC.
- Date processed
  
  MonthDayYear
- Method of Payment:
  
  Debit / CreditCash
- Check #
- Membership status:
  
  New MemberRenewalDenied
- Should be Empty:

WSU Student Speech-Language-Hearing Association

Mailing and Contact Address:

Permanent Address (if different):

Academic Status:

FOR OFFICE USE ONLY: