| The following personal details are for your PSPAWA membership. These details are NOT for publication so may include private contact details. |
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| SPA Member ID | |
| Title | |
| First Name | |
| Surname | |
| Mailing Address | |
| Mailing Suburb | |
| Preferred Phone | |
| Preferred Fax | |
| Mobile Phone | |
| Email | |
| | |
| Annual Membership Fee |
| Full Member - $190 | |
| Associate Member - $135 | |
Corporate Member - $90
(minimum of 4 therapists in the same practice) | Select Practice |
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New Name Badge
(check box if required) | |
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| The following information will be published on the PSPAWA website and printed publications. DO NOT include any information that is not for publication. |
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| Qualification | |
| Caseload | |
| Home Visit | |
| Clinic Based | |
| HIC Registered | |
| | |
| Caseload Areas |
| Acquired Adult Disorders | |
| Adolescent Language | |
| Articulation | |
| Attention Related Disorders | |
| Auditory Processing Difficulties | |
| Autism Related Disorders | |
| Business & Professional | |
| Cleft Palate | |
| Communication and Interpersonal Skills | |
| Dyspraxia | |
| Early Language | |
| Feeding (Dysphagia) | |
| Foreign Accent Modification | |
| Head & Neck Surgery | |
| Hearing Disorders | |
| Intellectual Disability | |
| Learning Difficulty | |
| Non Verbal Communication | |
| Nursing Home Consultation | |
| Paediatric Feeding | |
| Physical Disability | |
| School Age Language/Literacy | |
| Social Skills | |
| Stuttering | |
| Swallowing / Feeding (Dysphagia) | |
| Tongue Thrust | |
| Veterans Affairs | |
| Voice | |
| | |
| Foreign or Sign Language Specialty |
| Afrikaans | |
| Amerind (American Indian sign language) | |
| Baby Sign | |
| Cantonese | |
| Dutch | |
| English | |
| French | |
| German | |
| Gujurati | |
| Hebrew | |
| Hindi | |
| Italian | |
| Japanese | |
| Key Word Sign | |
| Makaton | |
| Mandarin | |
| Polish | |
| Swedish | |
| Tamil | |
| Zulu | |
| Other | |
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| Practice Details |
| Practice #1 | |
| Practice Name | |
| Practice Address | |
| Practice Suburb | |
| Practice Email | |
| Practice Phone 1 | |
| Practice Phone 2 | |
| Practice Fax | |
| Web Site | |
| | |
| Practice #2 | |
| Practice Name | |
| Practice Address | |
| Practice Suburb | |
| Practice Email | |
| Practice Phone 1 | |
| Practice Phone 2 | |
| Practice Fax | |
| Web Site | |
| | |
| Practice #3 | |
| Practice Name | |
| Practice Address | |
| Practice Suburb | |
| Practice Email | |
| Practice Phone 1 | |
| Practice Phone 2 | |
| Practice Fax | |
| Web Site | |
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| Comments |
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