National Student Speech Language Hearing Association

Combined Application for the NSSLHA Honors Program

Nominations for Chapter Advisor Honors and Chapter Honors must be received on or before January 31st.

Nominations for Member Honors must be received by May 1st. (Materials not received by the deadline will not be considered.)

For more information, contact Dawn Dickerson, NSSLHA Director of Operations, at ddickerson@asha.org.

Area of Consideration:

Chapter Advisor Honors

Chapter Honors

Member (Student) Honors

Nominee Information

Name of Nominee (Insert name of individual or institution being nominated) (Required):

Nominee(s)' E-mail Address (Insert e-mail address of individual or contact person of a chapter being nominated):

ASHA Membership #:

NSSLHA Membership #:

Chapter Endorsement

Chapter Advisor's Name (Required):

Chapter Advisor's ASHA Number:

Chapter President's Name (Required):

Chapter President's NSSLHA Number:

Please describe how the advisor's, chapter's, or individual member's work has advanced the mission of NSSLHA for students (500 words or less):

Contact Information:

All correspondence related to this application will be mailed to this address.

Name (Required):

Position (Required):

University Name (Required):

Street Address (Required):

City (Required):

State (Required):

Zip Code (Required):

Telephone # (Required):

E-mail address (Required):

Race/Ethnicity:

(Optional)

One of NSSLHA’s goals is to have its membership represent the multicultural diversity of the American society. Please let us know if the nominee meets one of these racial/ethnic categories:

	American Indians (including Alaskan Natives)
	Asian or Pacific Islander
	Black (not of Hispanic origin)
	Hispanic
	White (not of Hispanic origin)
	Other

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