Application Form Ordinary Membership

Transcription

1 Member ID: Office Use Only. Application Form Ordinary Membership 1 January - 31 December 2016 Join from 2 December and receive membership until 31 December Use this form if you are applying for Association membership for the first time or were last a member more than 12 months ago members will be sent renewal information in the mail. Please read Information for Applicants on the back page before completing this form. Please use BLOCK LETTERS. The original application form must be returned to National Office. Scanned or faxed applications will not be accepted. Membership Category Applied For (please tick) Ordinary Membership: Practising Non Practising Full-time Postgraduate Student Personal Information Family name: Former name: Given names: Date of birth: (Mr, Ms, Mrs, Miss, Dr) (if applicable) / / (used for security purposes to confirm identity on the phone) Day Month Year Contact Details Address: Suburb: State: Postcode: Phone: Mobile : (compulsory): *Part of Speech Pathology Australia s Member Benefits is the ability to access the Member only areas of our website and also to be part of our Association Distribution List. By providing us with an address you are automatically included on this list. If you do not wish to receive Association news please contact National Office. Twitter handle: Languages spoken: (Please list languages spoken other than English, including a Sign Language if applicable) Workforce Data If not born in Australia, your country of birth: Are you of Aboriginal or Torres Strait Islander descent? If not a recent graduate (i.e. graduate in past 3 years), how long have you worked in the profession? Qualifications NOTE: If you qualified as a speech pathologist overseas you are required to complete a separate application form to have your qualifications recognised. The form can be obtained from Speech Pathology Australia. If your qualifications have been previously assessed by Speech Pathology Australia, please state the assessment date below. Applicants who have undergone the Association s Overseas Qualifications Assessment are not required to resubmit their documents but further information may be requested if eligibility was assessed more than 2 years ago. Speech Pathology qualifications: University: Year of completion: For those with overseas qualifications, Date of Assessment

2 Employer/Private Practice Details (Practice 1) Please provide full details. Information may be used for public referrals and online searches. Employer/Practice: Address: Suburb State: Postcode: Phone: Mobile: Country: Practice type: Public Private Sole Prac Employer Employee NGO Academic Hours: Full Time < 35 hours < 25 hours Areas of special interest: Accent modification Aged Care Adult Language (incl. Aphasia) Auditory processing Augmentative & Alternative Communication (AAC) Autism spectrum disorders (ASD) Childhood speech sound disorders Craniofacial (incl. cleft) Disability Clinical population: Infants 0 2 years Children 2 5 years Children 5 12 years Adolescents: years Adults: years Aged (over 65) Adult motor speech disorders Head & neck cancers Head injury Hearing loss Infant Feeding Language/Learning (child & adolescent) Literacy Mental Health Progressive neurological disorders Services: Accident Cover NDIA (work or transport) Nursing Home Better Start FaHCSIA Palliative Care Corporate training School Visits Disability Care Telepractice DVA Veterans HCWA FaHCSIA provider Home Visits Medicare (approved services) Medico Legal Please tick if you do not want these details used for public referrals or online searches. Selective Mutism Social Communication Stroke Stuttering/Fluency Swallowing/Dysphagia Tracheostomy Voice Youth Justice Additional Employer/Private Practice Details (Practice 2) Please provide full details. Information may be used for public referrals and online searches. Employer/Practice: Address: Suburb State: Postcode: Phone: Mobile: Country: Practice type: Public Private Sole Prac Employer Employee NGO Academic Hours: Full Time < 35 hours < 25 hours Areas of special interest: Clinical population: Infants 0 2 years Children 2 5 years Children 5 12 years Adolescents: years Adults: years Aged (over 65) Accent modification Aged Care Adult Language (incl. Aphasia) Auditory processing Augmentative & Alternative Communication (AAC) Autism spectrum disorders (ASD) Childhood speech sound disorders Craniofacial (incl. cleft) Disability Adult motor speech disorders Head & neck cancers Head injury Hearing loss Infant Feeding Language/Learning (child & adolescent) Literacy Mental Health Progressive neurological disorders Services: Accident Cover NDIA (work or transport) Nursing Home Better Start FaHCSIA Palliative Care Corporate training School Visits Disability Care Telepractice DVA Veterans HCWA FaHCSIA provider Home Visits Medicare (approved services) Medico Legal Selective Mutism Social Communication Stroke Stuttering/Fluency Swallowing/Dysphagia Tracheostomy Voice Youth Justice Please tick if you do not want these details used for public referrals or online searches.

3 MEMBER DECLARATION Please read, sign and date I hereby apply for admission to The Speech Pathology Association of Australia Limited as a (Insert membership category) I declare that: a. I meet the Association's entry standards for the membership category I have applied for (as defined in the information provided with this application form). If a practising member I have: Worked a minimum of 1000 hours in speech pathology practice in the last five years (proof can be provided upon request). Or I have graduated within the last 3 years and have worked an equivalent of at least 200 hours per annum in speech pathology practice since graduation (e.g. 600 hours in 3 years post-graduation). Or I have graduated within the last 12 months (applicants who graduated from an Australian entry level speech pathology course within the preceding 12 months who have not commenced practice retain eligibility for Practising membership in the subsequent year). In signing this member application form to become a 2016 Provisional Certified Practising Speech Pathologist, I agree to undertake the following: sufficient professional development throughout 2016 to meet the annual requirements of the Professional Self Regulation program when I renew in 2017, including earning at least 12 points per annum in the PSR activity type mentoring, peer support, clinical supervision (Code M), completing free online SPA resources on Evidence-Based Practice and Ethics Education. In the 2017 renewal, if I have not yet met the requirements, I will renew again as a Provisional CPSP member in b. Both the information and the supporting documentation I have provided are a true and accurate record. c. I will abide by the Association's Rules and its Code of Ethics in my practice of speech pathology. d. I do not have any physical or mental impairment, disability, condition or disorder that detrimentally affects, or is likely to detrimentally affect, my ability to practise as a speech pathologist. e. I have not had my registration as a health practitioner refused, cancelled or suspended in a foreign country or in any Australian State or Territory. f. I have not had my registration as a health practitioner subject to any conditions, undertakings or limitations in Australia or overseas. g. I am not subject to any current investigation, inquiry or proceeding for professional misconduct, incompetence or incapacity, or any similar investigation or proceeding in relation to the practice of speech pathology in Australia or overseas. h. I have not had a finding made against me of professional misconduct, incompetence or incapacity or any similar finding in relation to the practice of speech pathology in Australia or overseas. i. I have not had any privileges, benefits or entitlements (including any relating to billing) regarding my practice as a health professional withdrawn, suspended or subject to any conditions or undertakings by any government body or agency in Australia or overseas. j. I have not been charged with any criminal offence in Australia or overseas. k. I have not been convicted of any criminal offence, or entered a plea of guilt or had a finding of guilt made against me by a court or tribunal for a criminal offence, in Australia or overseas. l. I am not involved in any current proceeding in respect of any criminal offence in Australia or overseas. Note: If you cannot declare all of the above matters, you must contact the Association and provide details of the reasons. Continuing obligation of members to inform Association of changes I agree to inform the Association, if during my membership, there is a change in the status of any of the above matters which I have declared. I will inform the Association within 7 days of becoming aware of the change. And, I acknowledge that I have read the Association s Privacy Collection Statement and I consent to the information about me contained in this form being collected by Speech Pathology Australia for the purposes of processing my membership application and for other purposes related to my membership and agree to the use and disclosure of personal information provided by me for the purposes of furthering the interests of the speech pathology profession and the objects of Speech Pathology Australia. Signature Date:

4 Application Checklist Please ensure you have completed all sections of the application form and have signed the member declaration. Please check you have provided the following: certified* evidence you have successfully completed your course. certified* evidence of any name change since completion of your course. if you graduated more than five years ago, evidence is required of at least 1000 hours of speech pathology practice within the last five years. evidence of enrolment in a full-time postgraduate speech pathology related program (if applicable). the required membership fee (including the Administration Fee). sent professional indemnity insurance application and payment direct to insurer, Guild Insurance (if applicable). *Certified copies means copies of your original documents must be signed and stated as 'a true and correct copy' by a Justice of the Peace or Commissioner for taking Affidavits (e.g. Accountant, Pharmacist, Police Officer, Nurse) Please contact National Office for further information: Address: Level 1, 114 William Street, Melbourne Vic 3000 Phone: or office@speechpathologyaustralia.org.au Website: Payment details for 1 January - 31 December 2016 Membership fee Tick appropriate membership category Australian mailing address (incl. GST) Overseas mailing address Provisional Certified Practising Speech Pathologist $525 $ Certified Practising Speech Pathologist $525 $ Non Practising $362 $ Full-time Postgraduate Student $275 $ Application Fee $33.00 $30.00 Total Payable: To Speech Pathology Australia: (Please Tick) Direct Debit Please see over to complete details (bank account only). An administration fee of $33 (incl. GST) applies. OR Cheque / Money Order Full amount OR Credit Card Full amount Card type: MasterCard Visa Card No: / Expiry date: Name on card: Signature of cardholder: In the event of a miscalculation of the amount due, I authorise the Association to debit the correct amount. Applies to credit card and direct debit payments only. Cheques that have the incorrect amount will be returned to be amended. How did you find out about Speech Pathology Australia? Tick One: Advertisement Internet Colleague / Word of mouth University Family/Friends Medicare Other I have been referred by (optional) Name: and/or Member Number:

5 Direct Debit Request Request and Authority to debit the account named below to pay Speech Pathology Australia Request and Authority to debit Frequency Insert the name and address of financial institution at which account is held Insert details of account to be debited Your Surname Your Given names you request and authorise Speech Pathology Australia to arrange, through its own financial institution, a debit to your nominated account any amount Speech Pathology Australia, has deemed payable by you (In accordance with the annual membership fee as outlined). This debit or charge will be made through the Bulk Electronic Clearing System (BECS) from your account held at the financial institution you have nominated below and will be subject to the terms and conditions of the Direct Debit Request Service Agreement. Payments will be debited on 20 th of each month or closest business day. Monthly Quarterly Yearly Please select your payment frequency. Financial institution name Address Name/s on account BSB number (Must be 6 Digits) - Account number Acknowledgment By signing and/or providing us with a valid instruction in respect to your Direct Debit Request, you have understood and agreed to the terms and conditions governing the debit arrangements between you and Speech Pathology Australia as set out in this Request and in your Direct Debit Request Service Agreement. An administration fee of $33 will be applied to your yearly total if you elect to pay by this method. If joining after February the first instalment will include an adjustment amount (e.g. if you join in June your first instalment will include all back dues from Jan to June and normal monthly or quarterly amounts will resume in July), and if renewing after the end of February the late fee of $44 (incl. GST) will be added to your total. By electing to pay by instalments you are also opting to have your membership automatically rolled over into the forthcoming year therefore authorising Speech Pathology Australia to continue deducting membership fees until you notify Speech Pathology Australia in writing to cease deductions or your membership is cancelled or withdrawn and outstanding fees are collected. You will be notified in writing of any change to your deductions at least 30 days prior to that change. The monthly deduction is one twelfth of the total of your annual membership. The administration fee will be spread across your payment frequency. I understand that instalments cannot be cancelled throughout the year and I am authorising Speech Pathology Australia to deduct the balance of my membership fees from the above bank account or by other means where appropriate. I authorise Speech Pathology Australia to deduct the amount indicated by my preferred means of payment. In the event of a miscalculation of the amount due, I authorise Speech Pathology Australia to debit the correct sum where the miscalculated amount does not exceed 10% of the total amount due. Insert your signature and address Signature Address Date / /

6 PSR Declaration for points earned in 2015 Name: As of 2016, to be able to join or renew as a Certified Practising Speech Pathology Australia (SPA) member you will need to first complete your PSR Declaration and meet the annual points requirement. All to complete - In completing this form, I declare and agree that: All the information I have given in this declaration is true and correct. I have the necessary forms and documentation to support this declaration. If requested, for the purposes of verification of compliance with the requirements of the PSR program, I agree I will supply forms and documentation as requested to the Senior Advisor Professional Education & Certification (PSR and CPD) at National Office. I am aware if any of the above information is found to be false or unsupported I will not be eligible to use the title of Certified Practising Speech Pathologist nor the post-nominals CPSP. Please tick the ONE relevant section of the declaration below: Renewing or new Practising and Full-time Postgraduate Student members: I have met the minimum annual requirement of 20 points for activities undertaken throughout the past year (or 2 years for those with an extension) including a minimum of 10 points in activities related to clinical practice. I am eligible to renew as Certified Practising member/cpsp. Renewing or new Practising and Full-time Postgraduate Student members who have NOT met the criteria: I am not eligible to renew as a Certified Practising member. I will be a Not Certified Practising member. Renewing or new Practising and Full-time Postgraduate Student members requesting an extension with this year s renewal or who had an extension with their 2015 renewal: I am eligible for an extension as I have been on extended leave (for parental leave, and/or leave of absence from practice for a period of more than 6 months, and/ or prolonged significant illness, and/or on compassionate grounds). I can supply supporting documentation if required. With this extension, I have from 1 January 2016 to 31 December 2017 to accrue the minimum annual requirement of 20 points (including a minimum of 10 points in activities related to clinical practice). I am eligible to renew as Certified Practising member/cpsp Non Practising and Re-entry members I am a participant in PSR and submitting PSR points, but I acknowledge that I cannot have Certified status graduates who were Provisional CPSPs in 2015 and have completed the requirements to move to full CPSP: I have met the requirements to renew as a Certified Practising Speech Pathologist with full CPSP status requirements including: completing the online SPA Evidence-Based Practice Independent Study Resource and Ethics Education Package; earning at least 12 points in the PSR activity type Code M in Mentoring and/or Clinical supervision activities since commencing employment; and I have worked at least 200 hours in the previous year in speech pathology practice postcourse completion graduates or mid-2015 graduates who were Provisional CPSPs in 2015 but have NOT completed the requirements to move to full CPSP: I have not met the requirements to renew as a Certified Practising Speech Pathologist with full CPSP status requirements and will renew as a Provisional CPSP and I agree that if I renew for 2017 without having met the requirements to move to full CPSP status, I will need to renew as a Provisional CPSP member or 2015 graduates in their first year of joining as a Practising member: I agree to undertake professional development activities as outlined in the Provisional CPSP document to renew as a Certified Practising member with Provisional CPSP status, and I agree that if I renew for 2017 without having met the requirements to move to full CPSP status, I will need to renew as a Provisional CPSP member. Please specify the number of points accrued for activities undertaken in 2015 in each PSR activity type in the table below. Please note there is a maximum of 12 points for each activity type (including for extension periods). PSR plan and log forms are NOT to be submitted with this declaration. PSR Activity Type PSR Points for activities undertaken in 2015 Independent study (Code IS) Attendance at conferences and expos (Code C/S) Attendance at workshops and SIGs (Code W/S) Teaching/Presenting (Code T/P) Research/Quality improvement (Code R/QI) Student supervision (Code S) Mentoring, peer support, clinical supervision (Code M) Participation in SPA Association activities (Code A) External study (Code ES) Mastering Technology (Code T) Other (Code O) Total - I hereby declare that I have accrued a points total of (total points)

7 Information for Applicants for Ordinary Membership Ordinary Membership Eligibility: Applicants for Ordinary Membership must have been awarded an approved primary qualification in speech pathology. There are four categories of Ordinary Membership: Certified Practising, Not Certified, Non Practising and Full-time Postgraduate Student. Applicants MUST ensure they meet all selection criteria AND provide ALL the required documents. Certified Practising A suitably qualified person engaged in the activities of speech pathology as a practitioner, administrator, educator, researcher or any combination thereof, for which they receive payment. Assessment Requirements: a. Australian Qualification If you qualified as a speech pathologist in Australia, you must provide: evidence you have successfully completed your course, i.e. a certified copy of your degree evidence of any name change since graduation, i.e. certified copy of your marriage certificate or deed poll in addition if you began your training during or after 1975 and graduated before or in 1994 proof you participated in 300 hours of face to face clinics or practicums throughout your course. if you graduated more than five years ago evidence is required of at least 1000 hours of speech pathology practice within the last five years. b. Non-Australian Qualification If you obtained your speech pathology qualifications outside Australia, it will be necessary for you to gain confirmation your qualifications meet the Association's minimum standards before applying for membership. You should contact Speech Pathology Australia for further information. Note: If you have previously obtained approval, please submit a copy of the letter accepting your qualifications with your application and state the date of your approval. Non Certified Member A suitably qualified person engaged in the activities of speech pathology as a practitioner, administrator, educator, researcher or any combination thereof, for which they receive payment, but do not meet the requirements of CPSP status. Non Practising Member A suitably qualified person not engaged in the activities of speech pathology as a Practising Member. Assessment Requirements: Applicants must qualify for and be able to be admitted to the Association as a Certified Practising Member. It is not necessary to provide evidence of practice during the previous five year period. Full-time Postgraduate Student Member A person suitably qualified in speech pathology who, at the time of application, will be engaged in full-time postgraduate study in a course recognised by the Association that will lead to the award of a Postgraduate Diploma, Master Degree or Doctor of Philosophy in speech pathology. Assessment Requirements: Applicants must qualify for and be able to be admitted to the Association as a Certified Practising Member. In addition, applicants for this category must provide evidence they are currently enrolled in a speech pathology related postgraduate course. Application Approval When applications are received, they are checked and then sent to Board for consideration. Acceptance to membership of The Speech Pathology Association of Australia Limited is subject to Board approval. Please note if the required documents are not received, considerable delays may be experienced before your application can be processed. Following approval, new members will receive an with their membership certificate. As a member of the Association you are encouraged to ensure you always keep records and details regarding your professional membership in a safe place. Membership Fee (Please note: membership is for a calendar year, i.e. 1 Jan 31 Dec) Please include the fee due with your application. Payment may be made by cheque, money order, credit card or direct debit. Payment should be made in Australian dollars only. Membership fees and costs are tax deductible items in Australia. Professional Self Regulation (PSR) Please refer to information available on the Association s website in the Professional Standards section to decide if you wish to participate in the PSR program. Professional Indemnity/Legal Expense Insurance Please refer to