Professional and Student Member ApplicationSTUDENT AND PROFESSIONAL MEMBERSHIP APPLICATION
Become a STUDENT OR PROFESSIONAL member of the International Association of Laryngectomees
COST: STUDENTS: $15 PER YEAR for Undergraduate and Graduate students
PROFESSIONALS: $35 PER YEAR for Speech-Language Pathologists, Physicians, Nurses, Physical Therapists, and other professionals interested in laryngectomee rehabilitation
BENEFITS:
ü Receive the quarterly IAL Newsletter “The IAL News”
ü Stay in communication with those who have undergone total laryngectomy and use alaryngeal methods of speech
ü Receive updates on new information and advances related to laryngectomee rehabilitation
ü Develop links and networks with other students and professionals throughout the United States and other countries worldwide
ü Expand your knowledge and experience in the area of laryngectomy
ü Foster your interest in this important clinical area of practice
ü Facilitate research
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REGISTRATION FORM
NAME: _____________________________________ SELECT ONE: STUDENT _____ PROFESSIONAL _____
MAILING ADDRESS: _________________________________________________________________________
CITY: ______________ STATE/PROVINCE: ________ ZIP/POSTAL CODE: _________ COUNTRY: __________
E-MAIL ADDRESS: _________________________ TELEPHONE (OPTIONAL): ___________________________
For Students: NAME OF UNIVERSITY: _________________________CITY/STATE: _______________________
AREA OF STUDY: _____________________________________ UNDERGRADUATE _____ GRADUATE ______
For Professionals: DISCIPLINE _______________ HOSPITAL _____ PRIVATE CLINIC _____ UNIVERSITY ____
PRIVATE PRATICE ______ Other _____________________________________________
INTERESTED IN IAL PROGRAM DEVELOPMENT OR LARYNGECTOMEE ADVOCACY? Yes _______ No _______
Please contact the IAL with any questions. Please make checks payable to THE IAL. Please mail registration form to:
The IAL
925B Peachtree St. NE, Suite 316
Atlanta, GA 30309
866.425.3678
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
All members receive a membership certificate and membership card upon request.
Please send a Membership Certificate and membership card: Yes ________ No ______
