Distinguished Students of Service Application

Applicant Contact Information

NSSLHA Account Number:

First Name:*

Middle Initial:

Last Name:*

Maiden Name (if applicable):

Mailing Address:*

City:*

State:*

(Select) Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas (except Canada) Armed Forces Europe, Canada, Africa, Middle East Armed Forces Pacific California Colorado Connecticut Delaware District Of Columbia Federated States Of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Postal Code:*

E-mail:*

University Name:

Region (locate your region):*

Are you a graduate or an undergraduate?

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?*

Education

Undergraduate Education

I am currently enrolled in an undergraduate program.*

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

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"):

Area:

If other, please specify.

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

Service Hours Performed

Local NSSLHA Chapter

Are you a member of a local NSSLHA Chapter?*

Enter 30 service hours.

Are/were you an officer in your local NSSLHA chapter?*

If yes, what office?

Enter 30 service hours.

Are/were you the chair of a committee in your local chapter?*

If yes, what committee did you chair?

Enter 30 service hours.

Did you volunteer for an event or participate in a fundraising activity hosted by your local chapter?*

If yes, what is the name of the event?

Enter 30 service hours.

Did you attend a local chapter meeting?*

If yes, how many meetings did you attend?

Enter 1 service hour for each meeting that you attended.

Did you participate/attend any other events not listed above?*

If yes, please provide more details.

Enter 1 service hour.

State Associations

Are you a student member of your state association?*

Enter 18 service hours.

Are/were you serving as a student member on a state association board?*

If yes, what was the board name?

Enter 18 service hours.

Are/were you participating, volunteering, or attending any state conventions?*

If yes, what is the name of the event?

Enter 18 service hours.

Did you volunteer for an event or participate in a fundraising activity for use at the state level?*

If yes, what is the name of the event?

Enter 18 service hours.

Did you attend a state association meeting?*

If yes, how many meetings did you attend?

Enter 1 service hour for each meeting that you attended.

Did you participate in any other events not listed above for a state association?*

If yes, please provide more details.

Enter 1 service hour.

Did you participate or attend state hill day activities (virtual hill days included)?*

Enter 18 service hours.

Did you read a state association website, newsletter, and/or other communications (blogging, webinar, etc.)?*

Enter 1 service hour.

National NSSLHA

Do you have national membership with NSSLHA?*

Enter 12 service hours.

Did you volunteer for an event or participate in a fundraising activity through National NSSLHA?*

If yes, what was the name of the event?

Enter 1 service hour.

Have you written/applied to NSSLHA Community Service or McKinley Grants?*

If yes, what is the name of the event or service?

Enter 12 service hours.

Have you ever applied to NSSLHA Honors?*

If yes, which honor did you apply for?

Enter 1 service hour.

Has your chapter ever been nominated for NSSLHA Honors?*

If yes, which Honor was that Chapter awarded?

Enter 1 service hour.

Did you participate in any other events not listed above?*

If yes, please provide more details.

Enter 1 service hour.

Have you read any NSSLHA publications (NSSLHA Now!, In the Loop, CICSD, etc.)?*

Enter 1 service hour.

Have you read any ASHA publications (The ASHA Leader, online journals, Perspectives, etc.)?*

Enter 1 service hour.

Have you ever visitied ASHA.org and/or NSSLHA.org?*

Enter 1 service hour.

Did you complete your profile on the ASHA Community?*

Enter 1 service hour.

Do you follow NSSLHA or ASHA on any social networking sites (Facebook, etc.)?*

Enter 1 service hour.

Have you participated on a video located on the NSSLHA YouTube channel?*

Enter 1 service hour.

Have you participated in an event for the NSSLHA Loves campaign?*

If yes, what was the event?

Enter 1 service hour.

Did you participate in any National NSSLHA recruiting activities?*

If yes, what was the activity?

Enter 1 service hour.

Have you participated in a National Hill Day sponsored by NSSLHA (virtual day included)?*

Enter 1 service hour.