CDAAC 2005 MEMBERSHIP APPLICATION / RENEWAL FORM

Membership in the Communicative Disorders Assistant Association of Canada includes: membership support; the professional designation CDAAC;
CDAAC News, a quarterly newsletter; access to the CDAAC Annual General Meeting and Conference; voting privileges; the option of attending two CDAAC run workshops; the CDAAC Membership Directory; along with other networking support and information. You will also receive the code to access employment information on the CDAAC web site.

Date: ______________________ Renewal:_____ New Membership:_____

NAME:
If this is a renewal, has your name changed?	If yes, previous name:
EMPLOYMENT ADDRESS
Name of Business:
Address (Street, Suite #):
City, Province:	Postal Code:
Telephone:	Fax:
Employer's website:	Business Email:
Population you serve:
Type of Employment: Full time__ Part time__	Permanent__ Contract__ Private__
HOME ADDRESS
Address (Street, Suite #):
City, Province:	Postal Code:
Telephone:	Home Email:

PRIVATE PRACTICE LIST: Would you like your name on a list available to consumers who contact CDAAC and are interested in private practice? Yes _____ No ____

If yes, which population(s) are you interested in serving: ______________________________

EDUCATIONAL INFORMATION: _______________________________________

If you are a new member or new graduate from Georgian or Durham college, please send your proof of graduation along with your completed application form and payment. If you are a student please provide a photocopy of your student card along with your application form and payment.

Languages Spoken: ____________________________________________________________

Would you like your name to be in the CDAAC Membership Directory? Yes _____No _____

Would you like to receive the CDAAC Newsletter by: Logging onto the website___ Mail ____

In completing this application, I confirm that I meet all the requirements for the membership for which I am applying.

Signature:___________________________________Date:___________________________

Membership is due by January 1^st of each year. The CDAAC website password will change January 1^st. Applications received after March 1^st will require a $10.00 late fee.

Please print and complete this application, enclose $ 55.00 membership fee (Individual) or $ 25.00 membership fee (Georgian/Durham College CDA Students) (cheques payable to: CDAAC), proof of graduation (copy of diploma, copy of official transcript, or signed letter from the college) or student status (copy of student card, copy of current transcript, or signed letter from the college) and mail to:

CDAAC
c/o Jen Walker
105 Partridge Cres.
Chatham, ON N7L 1E8

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Changes last made on: October 31, 2003