AG Bell Global Professional Council Member Application Form

AG Bell Global Professional Council Member Application Form

AG Bell values working with a global community. We are looking for professional leaders to join us from across the globe. If this is you, please complete the following application. The Council committee will select up to two professionals per country or region.
This form can be completed over multiple sessions. Be sure to click "save" to save your work if you are not ready to submit. Once you have completed your application, click "save" and "submit" at the bottom of this form.
Due: September 15, 2025 at 11:59 pm ET (Washington, D.C.)
Name*

First NameLast Name
Please share the name of your place of work:
Preferred Email for Communications*
example@example.com
Re-enter your above email.*
example@example.com
Phone Number/WhatsApp Number*

Area CodePhone Number
Address*

CityState / Province

Postal / Zip Code
Country of Residence*
Spoken Languages Used*
I am a professional who provides listening and spoken language or a related service and have professional licensing or certification as a/an (check all that apply):*

AudiologistDeaf EducatorPsychologistSocial worker or Licensed CounselorListening and Spoken Language Specialist (LSLS Cert. AVEd or LSLS Cert. AVT)Speech Language PathologistEarly Childhood EducatorEarly Intervention provider specialized in deaf educationSpecial EducatorPhysicianOther
If you chose other, what is your profession?*
I have provided listening and spoken language or related services for the following length of time:*

0-3 years4-7 years8-12 yearsMore than 13 years
Please identify your country’s progress and comment on the following questions. You may consult with others in your country to learn this information if you are unsure.
What is the status of newborn hearing screening?*

Not established or established in the minority of the countryBeginning but not yet universalEstablished universally or established in the majority of the country
Comment:
What is the status of diagnostic audiology services?*

Not established or established in the minority of the countryNot yet universal; diagnosis later than 3 monthsEstablished universally or established in the majority of the country
Comment:
What is the status of fitting of hearing technology on children?*

Not established or established in the minority of the countryNot yet universal; access to technology no later than 3-6 months of agePrograms to fit hearing technology early (before 3 months of age) are universally available
Comment:
What is the status of early intervention for children?*

Not established or established in the minority of the countryNot yet universal; entrance in intervention occurs later than 6 months of age or not is not availableEstablished universally or established in the majority of the country
Comment:
What is your experience offering family-centred early intervention?*

No experienceAt least 1-3 years' experienceAt least 3 years' experience
Comment:
Are you a LSLS Certified AV professional, working/wanting to work towards the certification and/or aligned with AG Bell Association’s mission, vision and values?*

I do not have LSLS certification. As well, I do not have one of the three degrees currently required to seek certification (audiology, deaf education, speech-language pathology)I would like to work towards LSLS certification and do have one of the three degrees currently required to seek certification (audiology, deaf education, speech-language pathology)I am currently pursuing LSLS certificationI am a LSLS Cert. AVT or LSLS Cert. AVEd
Comment:
Please share how you engage with your local community (e.g. lead or participate in parent groups, liaise with government/serve or served on committees for professional organisations/provided professional training). Share any engagement activities (including face-to-face and online) in the comment section:*

I spend nearly all of my time providing services and am not engaged outside of my work settingI am interested in becoming engaged, but have not yet had opportunitiesI have recently engaged in leadership opportunitiesI am highly engaged
Comment:
Are you willing to collaborate with other professionals and AG Bell Association through committed work?*

I am open to collaboration but have had no opportunities to dateI have collaborated on at least 2 opportunities in my host country or with AG BellI have collaborated on several opportunities in my host country or with AG Bell
Comment:
Do you have any additional information you would like to share with us?
If you are selected and then invited to participate as a member of the AG Bell Global Professional Council (GPC), you are expected to agree to commit to the following: I would be expected to participate in two online AG Bell professional leadership 2.5-hour training forums (e.g., April, September) each year (Dates and times for each forum will be determined by the Council). If for any reason, I cannot attend, I would be willing to watch the video and participate in a separate session with one of the AG Bell lead facilitators. If selected, I understand I would be expected to participate as an AG Bell Association representative for my country and would be a member of the Global Professional Council for a one-year term (which is renewable two additional times for a maximum of a three-year term). Each annual year runs from January through December for the purpose of this council. I understand that I am under no obligation to continue after my first term. I also understand that I am a volunteer and that if circumstances change in my life, I can for any reason, step down from this volunteer membership role. If selected, I understand I would be expected to lead a minimum of one professional learning activity annually. I will be expected to comply with AG Bell's policy regarding conflict of interest. I also recognize that AG Bell has the final decision regarding this application.
Please check that you have read the above paragraph related to expectations. Please be patient with us. The process of developing the Global Professional Council (GPC) will take time.  Should you have any questions or need to reach us, please contact AG Bell at info@agbell.org.   Thank you!   AG Bell*

I have read the above paragraph and understand what the expectations are.
Should be Empty: