WSUSSLHA membership application form

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:

Make payment via credit/debit card via our WSUSSLHA online store. Then email completed membership form to: wsusslha@wichita.edu
Bring form and dues to Department of Communication Sciences and Disorders - 401 Ahlberg Hall or give to a WSUSSLHA officer.
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.

E mail

example@example.com

Permanent Address (if different):

Street

City

State/Country

Zip+4

Academic Status:

Choose one:

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

WSU Student Speech-Language-Hearing Association

Mailing and Contact Address:

Permanent Address (if different):

Academic Status:

FOR OFFICE USE ONLY: