NZSTA Membership Renewal Form 2010

Full Name (Required)

Change of Name

If you have previously been a member of the NZSTA under a name different to that provided above, please provide your previous name here.

NZSTA Membership Number

Email Address (Required)

Please enter the email address you would like to receive NZSTA updates at. If you do not have a current email address, please enter "none".

Phone Number (home)

Enter if changed from summary information sent to you

Phone number (work)

Enter if changed from summary information sent to you

Phone number (mobile)

Enter if changed from summary information sent to you

Mailing Address (Required)

Postcode (Required)

Employer's Name & Address

Enter if changed from summary information sent to you. If you are currently not working please indicate this as appropriate.

Ethnicity

Enter if different from summary information sent to you by selecting one or more of the options below.

NZ European

NZ Maori

Pacific Islander

American

European

Canadian

South African

Chinese

Indian

Other

Sector/s Working in

Enter if different from summary information sent to you. Mark as many as apply.

District Health Board

Health, other than DHB

MOE - Special Education

School

Private Practice

Charitable Trust

University

Not Practising

Other

SLT Qualifications Attained

For each SLT qualification attained please list the year achieved, the name of the qualification, and the training institution. e.g. 2007 BSLT, University of Canterbury

Proof of Qualifications

If you have not previously sent a copy of your SLT Qualification/s (does not have to be certified copy) please either upload it here or post a copy.

How do you want to Receive Communication Matters? (Required)

Please indicate how you would like to receive Communication Matters, the quarterly newsletter. Back issues are available on the website.

An electronic copy of Communication Matters (pdf format)
A hard copy of Communication Matters in the post

Areas of Interest

Please list any of particular areas of interest (related to speech-language therapy).

Continuing Professional Development Form

It is a requirement to maintain full membership to complete and file your Continuing Professional Development record for 2009. Please upload it here. The link to the CPD form is available by clicking on the Membership menu - it is under the heading 'Applying for Membership or Membership Renewal'.

My 2009 CPD Form: (Required)

Please select one of the following as appropriate.

is attached
will be posted as a hard copy
will be submitted within the next four weeks
does not need to be submitted as I am not currently practising as an SLT

Agreement with Declaration (Required)

A. I have read and understand the NZSTA Code of Ethics (2008) and I agree to abide by this Code and any subsequent amendments. I understand that, should I cease to be a member, any complaint against me may be directed to the Health and Disability Commissioner for investigation. B. I agree to abide by all standards required to maintain membership and I understand that, once I receive membership, my membership status may be made available to the public. C. I declare that the information provided in this form, and all other relevant documentation provided, is true and correct.

I understand, and agree to, all the items outlined in this declaration.

Disclosure - Offences (Required)

Have you ever been convicted of a criminal offence or an offence related to the practice of speech-language therapy? If "yes", please send details to the Executive Officer.

No
Yes

Disclosure - Professional Practice (Required)

Have you been the subject of a finding of professional misconduct, incompetence or incapacity by your employer or any other body? If "yes" please send details to the Executive Officer.

No
Yes

Disclosure - Disciplinary (Required)

Have you ever been disciplined or sanctioned, or are there any disciplinary proceedings pending against you before any professional association, professional licensing authority or board, or other professional regulatory body? If yes", please send details to the Executive Officer.

No
Yes

Membership Category (Required)

Please select the appropriate category. Please go to membership categories for more information.

Full Member working 26 hours or more per week - $337.50
Full member working less than 26 hours per week - $236.25
Provisional Member - $337.50 (less any discount for previous student membership - see question below)
Non-practising Member - $225
Associate Member - $225
Life Member - No fee

New Graduates Only

Only for new graduates in 2010 who were a student member of NZSTA in 2009. Please select the years in which you were a student member of the NZSTA. You are eligible for a discount of $33.75 discount off your provisional membership for each year of student membership.

2009 ($303.75 membership fee)

2008 ($270.00 if a student member in 2008 and 2009)

2007 ($236.25 if a student member in 2007, 2008 and 2009)

2006 ($202.50 if a student member in 2006, 2007, 2008 and 2009)

Declaration - Have You Worked More Than 1,000 Hours as an SLT in the last five years? (Required)

I hereby declare that I have worked more than 1,000 hours in the past five years as a speech-language therapist which is a requirement to maintain full membership.

Yes
No
Not applicable as I am not applying for full membership

Declaration - Hours of Work (Full Members) (Required)

I hereby declare that I am working the following hours as a speech-language therapist and I agree to notify NZSTA in writing of any increase in hours which would take me into the higher category.

I am or will be working 26 hours or more per week this membership year
I am working less than 26 hours per week
Not applicable as I am not applying for full membership

Payment Options (Required)

Please indicate your payment method by checking one of the boxes below. Details of how to make payments will come up once the form has been submitted.

Payment by credit card
Payment by cheque made out to NZSTA
Electronic or direct payment
My employer is paying my membership fees, please send an invoice to me to give to my employer.

Date of Payment

If you have selected "electronic or direct payment" as your payment method, please indicate the date on which the payment has been / will be made.

Message

Any message you would like to include

Sections

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NZSTA Membership Renewal Form 2010

This form is only for speech-language therapists who have been members of the NZSTA in 2009 and wish to renew their membership for 2010.

Details of how to make payment will come up once the form has been submitted.