866-425-3678 office@theial.com

Student and Professional Membership Application

Become a STUDENT OR PROFESSIONAL member of the International Association of Laryngectomees

STUDENTS: For Undergraduate and Graduate students

PROFESSIONALS: For Speech-Language Pathologists, Physicians, Nurses, Physical Therapists, and other professionals interested in laryngectomee rehabilitation

BENEFITS:

  • Receive the quarterly IAL Newsletter “The IAL News”
    • Stay in communication with those who have undergone total laryngectomy and use alaryngeal methods of speech
    • Receive updates on new information and advances related to laryngectomee rehabilitation
    • Develop links and networks with other students and professionals throughout the United States and other countries worldwide
    • Expand your knowledge and experience in the area of laryngectomy
    • Foster your interest in this important clinical area of practice
    • Facilitate research

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REGISTRATION FORM

NAME: _____________________________________   SELECT ONE:   STUDENT _____ PROFESSIONAL _____

MAILING ADDRESS: _________________________________________________________________________

CITY: ______________   STATE/PROVINCE: ________   ZIP/POSTAL CODE: _________ COUNTRY: __________

E-MAIL ADDRESS: _________________________   TELEPHONE (OPTIONAL): ___________________________

For Students: NAME OF UNIVERSITY: _________________________CITY/STATE: _______________________

AREA OF STUDY: ______________________­­­­_______________ UNDERGRADUATE _____ GRADUATE ______

For Professionals: DISCIPLINE _______________ HOSPITAL _____ PRIVATE CLINIC _____ UNIVERSITY ____

PRIVATE PRATICE ______      Other _____________________________________________

INTERESTED IN IAL PROGRAM DEVELOPMENT OR LARYNGECTOMEE ADVOCACY?   Yes _______ No _______

 

 

Please contact the IAL with any questions. Please mail registration form to:

 

The IAL

925B Peachtree St. NE, Suite 316

Atlanta, GA 30309

866.425.3678

theialoffice@gmail.com This e-mail address is being protected from spambots. You need JavaScript enabled to view it

 

All members receive a membership certificate and membership card upon request.

Please send a Membership Certificate and membership card:   Yes ________  No ______