Affiliate Membership Form
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Applications for affiliate membership will be considered from the following groups. Applications will be considered individually:


  • Therapists who cannot fulfil the full membership criteria but have temporary membership with RCSLT and HCPC, i.e. overseas therapists;
  • Overseas therapists (with temporary membership of RCSLT and HCPC) who treat only in the language in which they qualified, should state that language below form (Section: "I can treat in English and other languages") and can only be listed as treating in that language in the records;
  • Therapists who are registered members of RCSLT and HCPC but are without 2 years postgraduate experience. Membership will be reviewed by the committee after two years and full membership offered to those who qualify;
  • Therapists who are registered members of RCSLT and HCPC and are returning to work following a break of over 5 years;
  • Newly qualified therapists who are receiving supervision from a full ASLTIP member. Membership will be reviewed by the committee after two years and full membership offered at the renewal rate if they qualify.
    Name of supervisor

GENERAL DETAILS
Title: *
SURNAME: *
WORK EMAIL: *
Have you ever been a member of ASLTIP in the past?  
FIRST NAME: *
LOGIN EMAIL: *

(This will be the username)

WORK ADDRESS FOR CORRESPONDENCE:
Line 1: *
Line 2:
Line 3:
Town : *
Postcode: *

i.e: W3 0RX

Country: *

Change If not UK

HOME ADDRESS FOR CORRESPONDENCE:
LINE 1: *
LINE 2:
LINE 3:
TOWN : *
POSTCODE: *

i.e: W3 0RX

COUNTRY: *

Change If not UK

Please note that Home Phone No is not visible to the general public – if this is to be your contact number please also enter it under Work Phone No
HOME PHONE No
MOBILE PHONE No *
PERSONAL WEBSITE

e.g. www.yourwebsite.com

WORK PHONE No
FAX No
I can treat in English (and other languages)

Please specify which:

   
QUALIFICATIONS:
YEAR OF QUALIFICATION: *
RCSLT MEMBERSHIP No: *
HCPC REGISTRATION No: *
NAME OF PRESENT WORK PLACE: *

IF YOU ARE NOT WORKING AT PRESENT, PLEASE COMPLETE THE FOLLOWING:

State length of break in service: And give details of last SLT employment and any courses attended in the interim:

Chars. left:

NUMBER OF YEARS WORKING EXPERIENCE AS SLT: *
PRESENT POSITION: *
IS THIS AN NHS POST? *


If less than 2 years in current post, please give details of previous employment:

Chars. left:

HOW LONG IN POST?
As an affiliate member you will be entitled to all of the back-up services of ASLTIP but your name will not be given to enquirers nor will you be entitled to vote or use the ASLTIP title or logo and will not be entitled to sponsorship or supported places rights. The subscription rates are: New Affiliate Member = £50.00 / Annual Renewal = £50 (once only – thereafter a full renewal fee of £110.00 will be due).
After submitting the automated online application form please ensure that the following documents are either attached online to your application form, or emailed to office@helpwithtalking.com as attachments:

A copy of your HCPC registration document, or membership card
A copy of your current RCSLT membership card, renewal letter or confirmation email from RCSLT

Please include all documents in a ZIP file and attach below (or email as attachments – see above)


Please make a payment of £150 to the following bank details, using your surname as the reference so that the payment can be identified:

Bank
: Lloyds
Sort Code: 30-94-57
Account Name: The Association of Speech & Language Therapists in Independent Practice
Account No: 27897560
Please note that cheques nor card payments can be accepted.
FEES Membership runs for 12 months from your joining date and the subscription for Affiliate membership is £50. You will be invoiced 12 months after your initial payment. The renewal fee of £50 can only be applied once. Thereafter it is a requirement that full membership is taken out.
PLEASE NOTE: If you do not include the RCSLT and HCPC documentation referred to above, it will not be possible to process your application.
Data Protection Act
The information you provide on this form will be processed by ASLTIP and will be used for:
1. Inclusion on the ASLTIP list of independent therapists given to the general public (unless otherwise indicated to the office, or you are a restricted member).
2. Inclusion on the ASLTIP databases currently held on its website and on the internal database at the administration office.
3. Inclusion in the online search if you choose to be a website member (see above) and are currently available.
4. Distribution of information in regard to ASLTIP’s services, activities, complaints procedure, etc.
5. Any Member Searches available to other ASLTIP members within the secure, password-protected Members Area of the ASLTIP website.
I certify that the above information is correct. I agree to abide by the standards and guidelines of the Association.

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