Membership Application Form
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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:

AGE RANGE: *
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?
ASLTIP has a searchable database on the website www.helpwithtalking.com to enable members of the public to search for a therapist online without having to contact the office. It is an effective way to advertise your practice. To take full advantage of membership of ASLTIP, you are advised to have an email address, however it is not obligatory. You can also be a website member without an email address. The subscription rates are: New Member is: £150.00 & Renewal fee is: £110. All fees include website inclusion – if you do not want your name/details to appear in the public domain on the website please sign below*. Please note that no home addresses or home telephone numbers are visible in the public domain.

I do NOT want my practice and contact details to be made available online on the ASLTIP website database.

Members who are available, but who do not choose to be website members, will be included in searches carried out by the Administrator in response to direct requests to the office.
FEES Membership runs for 12 months from your joining date and the annual subscription is £150.
You will be invoiced 12 months after your initial payment (renewal fee currently £110).

Alongside submitting the form online, send the following documents to ASLTIP (Woodside – Coleheath Bottom – Speen – Princes Risborough – Bucks – HP27 0SZ):

o A photocopy of your current RCSLT membership card showing the expiry date
o A photocopy of your HCPC registration document
o Membership Fee: £150

Please include all documents in a ZIP file and attach below
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.

Please enter this security code below