American Speech-Language-Hearing Association

NSSLHA Regional Councilor Application

(Region 1, Region 3, Region 4, Region 6, Region 9, Member-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 on the Council is a two-year commitment. Candidates may apply if they will be enrolled in a program for at least three academic semesters of the 2-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 2-year 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 Regional Councilor that I must be a current national member of NSSLHA.*

 I understand that it is mandatory for the Regional Councilor 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 a Regional Councilor may be 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.


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.*

The biggest benefit that NSSLHA gives to students is...*

What are your leadership strengths and weaknesses and what new experiences and skills do you intend to gain as a regional councilor 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

Share This Page

Print This Page