American Speech-Language-Hearing Association

Grassroots Captain Sign Up Form

Speak Out, Be Heard

Grassroots Captains are needed from every congressional district and state across the country. These Captains serve as the primary contacts with their U.S. Senators and Representatives in order to establish valuable relationships and increase awareness of the issues that face speech-language pathology and audiology. Captains will also help galvanize their speech-language pathology and audiology colleagues in federal advocacy initiatives.

If you are interested in serving as a Grassroots Captain, please complete the form below.

* indicates required field.

First Name:*

Last Name:*

Mailing Address:*

City:*

State:*

Zip Code:*

Phone Number:*

E-mail:*

I would like to serve as a Captain for my:

*If only one senator, specify who.

Please describe your current relationship with your Representative/Senator(s).

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