Participant Information

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* 1. Completion Date  (Your CE assessment will be graded and your participation documented in the next group submission when this group activity ends, on or shortly after June, 2022)

Date

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* 2. Name (First and Last)

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* 3. Address

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* 4. Address Line 2

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* 5. City, State and Zip

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* 6. Daytime Phone Number

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* 7. Alternate Phone Number

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* 8. Email:

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* 9. OSLHA Membership Number

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* 10. To Confirm Your Participation in This Activity, Do you Prefer a Certificate of Participation Emailed to You or Submission of Your Attendance to the ASHA Registry?  (Your CE assessment will be graded and your participation documented in the next group submission when this group activity ends, on or shortly after June, 2022)

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* 11. ASHA requires that you be an ASHA Member or CCC holder or you be licensed or credentialed to practice speech-language pathology (SLP) or audiology or be preparing to practice in order to be eligible to earn ASHA CEU's.  How are you qualified for ASHA CEU's?

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