You do not have JavaScript Enabled on this browser. Please enable it in order to use the full functionality of our website. NSSLHA Delegate Application

NSSLHA Regional Delegate Application

(Region 1, Region 3, Region 4, Region 6, Region 9, Delegate-at-Large)

Applications, letters of recommendation, and resumes must be received by March 1, 2015. Application materials are not complete until all components are received in the national office:

  • completed application
  • resume
  • statement of interest
  • reference letters from one professional (i.e., teacher, advisor, mentor, supervisor) and one student

Term Requirements

A position as a delegate is a two-year commitment (one year if you are a Member-at-Large delegate). A candidate may apply if they will be enrolled in a program for at least three academic semesters of the 2-year term (or 2 academic semesters for the Member-at-Large delegate). Graduate students are eligible to apply even if they will be in a Clinical Fellowship or externship for 3–6 months of the term (and have not applied for the Certificate of Clinical Competence [CCC's]).

More information is available on the NSSLHA Governance webpage.

* indicates required field.

Applicant Information

First Name:*

Last Name:*

NSSLHA Account Number:*

Region (locate your region):*

Contact Information

Mailing Address (correspondence will be sent to this address):*


State or Province:*

Postal Code:*

Phone Number:*

E-mail Address:*

Applicant Profile

Are you a member of your local chapter?*


Are you a student in a speech-language pathology assistants program?*


Are you in a Distance Learning Program?*


Are you an officer of your local NSSLHA chapter?*


Share your social networking sites:

Please include a page or blog name for any social networks you use or author.







Undergraduate Education

I am currently enrolled in an undergraduate program.*


If yes, I expect to receive my bachelor's degree (MM/YYYY):

Undergraduate Area:


If other, please specify.

Name of University Awarding Bachelor's Degree:

Graduate Education

I am currently enrolled in a graduate program.*


If yes, I am in my:


I expect to receive my graduate degree (MM/YYYY):

University Awarding Degree (not applied or accepted, use "undecided"):

Graduate Area:


If other, please specify.

Area of Professional Interest (e.g., child language, geriatrics, undecided):


 I understand that if I am selected for the position of Delegate that I must be a current national member of NSSLHA.*

 I understand that it is mandatory for the Delegate to attend the summer orientation meeting. All travel and hotel expenses are covered by the national office. *

 I understand that a Delegate is required to serve on at least one NSSLHA Committee.*

 I understand that if selected for the position that my role is to assist the Regional Councilor in developing and implementing the goals for the Region.*


One of NSSLHA's goals is to have its membership represent the multicultural diversity of American society.



Tribal Affiliation (for American Indians - including Alaskan Natives):


You may cut and paste your resume from a Word document into this area or send your resume to as a separate attachment. If you choose to send your resume via e-mail, please type "sending via e-mail" in the space provided. If you are copying and pasting your resume below, please note that any formatting in Word will not transfer into the following box.*

Statement of Interest

Please provide the NSSLHA Executive Council with a statement that explains your interest in the position. Please answer all questions and limit your responses to 500 words or less.

What are your leadership strengths and weaknesses and what new experiences and skills do you intend to gain as a delegate to help you grow?*


Please have one professional and one student provide references on your qualifications for this position. Please encourage them to send their reference letters electronically to


Send an electronic photograph that may be used for publication to

Documents and Attachments

You may share electronic documents or publications, videos, or PowerPoint presentations that will demonstrate your abilities as a leader. Send these attachments to

ASHA Corporate Partners