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NSSLHA Member-at-Large Application

All Regions

Applications, letters of recommendation, and resumes must be received by March 1, 2014. 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

The position of Member-at-Large is a one-year commitment (July – June). Candidates may apply if they will be enrolled in a program for at least 1-academic semester of the 1-year term. Graduate students are eligible to apply even if they will be in a Clinical Fellowship or Externship for 3 – 6 months of the 1-year term (and have not applied for the Certificate of Clinical Competence -- CCC’s).

More information is available on the NSSLHA Governance Page.

* indicates required field.

Applicant Information

First Name:*

Last Name:*

NSSLHA Account Number:*

Region (locate your region):*

Contact Information

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



Postal Code:*

Phone Number:*


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):



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"):



If other, please specify.

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


 I understand that if I am selected for the position of Member-at-Large that I must be a current national member of NSSLHA.*

 I understand that it is mandatory for the Member-at-Large to attend three Executive Council meetings. The Council meets in the summer (this is an orientation meeting); in the fall (during the ASHA Convention in November; and in the spring (at the national office in Rockville, MD). All travel and hotel expenses are covered by the national office.*

 I understand that the Member-at-Large is selected to serve on one or two American Speech-Language-Hearing Association (ASHA) boards or committees (meeting dates vary). Attendance at those meetings is mandatory. All travel and hotel expenses are covered by the national office.*

 I understand that if selected for the position I will allow the NSSLHA Executive Council to select the delegate for my position who will be responsible for completing my term should I not be able.*

 I would like to be considered for the delegate position if I am not selected as a regional councilor.

Race/Ethnicity (Optional)

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 below.*

Statement of Interest

Please provide the NSSLHA Executive Council with a statement that explains your interest in the position. Please answer all questions below 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 the member-at-large to help you grow?*

I would like to see NSSLHA …*

The biggest benefit (tangible or intangible) that NSSLHA gives to students is…*


Please have one professional and one student provide references on your qualifications for this position. Please encourage them to send their reference letters electronically by April 5, 2013 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

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