Future Doctor of Audiology Student Membership Application

Note:These fields are REQUIRED
Student Member Information:
First Name:
Middle Initial:
Last Name:
Gender: Male   Female
Highest Degree Currently Completed:
Street Address
City:
State:
Zip:
Telephone:
Alternate Telephone:
University E-mail Address:
Personal E-mail Address:



Required Credentials:
Au.D. University/Institution:
Expected Graduation Date:
Institutional Website
YES, I agree to abide by the ADA Code of Ethics



Future Practice Setting:
Is Private Practice Your Planned Future Practice Setting? Definitely Yes
Very Likely
Maybe
Very Unlikely
Definitely No
Which type of position are you most interested in? Ownership   Non-Ownership
If your career interest is private practice,
please describe in one short sentence why:
Does your University require business courses
as part of your Au.D. Curriculum?
Yes   No
Have you had the opportunity to do clinical
rotations in a private practice setting? 
Yes   No



Clinical Interests: (please check all that apply)
Audiologic Diagnostic Assessments
Vestibular Assessments and Rehabilitation
Hearing Aid Selection, Fitting and Management
Pediatric Testing
Cochlear Implants
Tinnitus Assessment and Treatment
Electrophysiologic Testing
Auditory Processing Assessment and Treatment
Industrial Testing
Intraoperative Monitoring
Hearing Conservation
Aural Rehabilitation
Assistive Listening Devices
Implantable Hearing Aids
Other:   



Preferred Geographic Setting: (please check all that apply)
Urban
Suburban
Rural
International



Membership Communication Disclosure:

By applying for ADA membership, you agree to accept postal mail, electronic mail, telephone calls, facsimiles and other communications from ADA unless you notify us in writing that you do not wish to receive such communications.

For facsimile communications, please complete the following:

Would you like to receive Facsimile communications on behalf of ADA? Yes   No
Fax Number(s)
May ADA provide your contact information to industry firms supplying products and services to audiologists? Yes   No



Membership Options
I am interested in FREE Annual Student Membership, available to students who have a desire to pursue private practice. I apply for my student dues to be underwritten by an ADA Student Membership Scholarship, subject to approval by ADA. I agree to allow the sponsor access to my contact information including both my university and personal email addresses. No payment information is needed.
Referral
If you were referred by another ADA member, please provide his or her name.



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