SLP Application Form - World Stop Stuttering Association

Your Personal Information

Your Name(Required)

First Middle Last

Your Email Address(Required)

Enter Email Confirm Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Professional Information

Where were you certified as an SLP?(Required)

Year of your Certification(Required)

List Any Languages You Speak

Have you ever stuttered?

Yes

No

Have you ever provided therapy to a stutterer?

Yes

No

If yes, how many have you treated?

Documents for Verification

Attach a picture of yourself

Upload your picture in .jpg or .png format

Drop files here or

Accepted file types: jpg, jpeg, png, Max. file size: 25 MB.

Give brief description of your work experience or attach a resume.

Upload your resume in .pdf format

Drop files here or

Accepted file types: pdf, Max. file size: 25 MB.

Attach a copy of your SLP Certification (optional)

Upload your certification in .pdf format

Drop files here or

Accepted file types: pdf, Max. file size: 25 MB.

Agreement(Required)

I understand that (1) the above information will not be made public without my prior approval, (2) WSSA does not guarantee the success of its program and reserves the right to cancel this program at any time without notice to anyone and to deny my application and/or rescind my free membership at any time for any reason at WSSA’s sole option.

I agree

I do not agree

SPEECH LANGUAGE PATHOLOGIST APPLICATION

Fill Out the following application to gain access to our Program for Speech Professionals

Your Personal Information

Professional Information

Documents for Verification