Rhode Island Speech-Language-Hearing Association

Contact Information:
PO Box 9241
Providence, RI 02940
401-455-7472

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Membership Application
2008 RISHA MEMBERSHIP APPLICATION
Valid 1/1/08- 12/31/08

Name
Address
Phone
Email
Employer
Employer Address
Work Phone
Occupation/Title
Area of Interest/Specialty
Highest Degree/Where
Dept. of Health Licence	Yes No
Dept. of Ed. Certificate	Yes No
ASHA Certification	CCC-CF CCC-SLP CCC-AUD
ASHA Member	Yes No
Type of RISHA membership you are applying for	Active Associate Student
If Student, attending school
Membership Categories
$50 Active Member ($45 if postmarked by 12/31/07) Voting member-Master's degree or higher in SLP or AUD $45 Associate Member ($40 if postmarked by 12/31/07) Non-voting member-Bachelor's degree in SLP or AUD or individuals with a professional interest $10 Student Member Non-voting member-Actively pursuing college/university training in SLP or AUD
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Please make check payable to RISHA Mail to: RISHA P.O. Box 9241 Providence, RI 02940