Membership application - New Zealand Speech-language Therapists' Association

Note:

If applying for membership via the Mutual Recognition Agreement or Qualifications Authority please complete an application form and post with supporting documents instead of using this form.

* These fields are required

Your Details

Title *

First Name *

Last Name *

Maiden Name

Gender *

Ethnicity *

Which ethnic group do you belong to? Please tick the box or boxes which apply to you.

NZ European

Māori

Samoan

Cook Island Maori

Tongan

Niuean

Chinese

Indian

Other

Please Expand on Other

Email Address *

Confirm Email Address

Password

Contact Details

Postal Address

Address line 1 *

Address Line 2

Suburb *

City *

Region*

Postcode *

Country *

Phone Numbers

Primary Phone *

Secondary Phone

Phone Work

Membership Details

Membership Category *

Current Employment Status *

Student Member

Speech Language Therapy Related Activity *

Registered members (excluding Return to Practice Members and New Graduate Members) are required to have worked more than 1,000 hours over the past five years in a speech language therapy related activity.*

I declare that I understand and meet this requirement

CPD *

Registered members (excluding New Graduate Members) are required to be involved in Continuing Professional Development and keep their CPD log up to date.

I declare that I understand this requirement and accept it is my responsibility to keep my CPD log up to date. I am aware that an NZSTA CPD Log audit will be undertaken during the year.

Supervision *

Registered members are required to be involved in professional supervision at least four times per year as part of abiding by the NZSTA Principles and Rules of Ethics NZSTA Supervision Document

I declare that I I declare that I understand this requirement and will engage in structured professional supervision in abidance with the NZSTA Supervision Policy

Public *

I understand that, if applying to become a student member I must be:

Enrolled in an NZSTA accredited speech-language therapy training programme, or
Hold an NZSTA recognised qualification and enrolled full-time or part-time in a speech-language therapy-related course of post-graduate study and not be receiving remuneration for any speech-language therapy-related work, or
Be enrolled full-time in a speech-language therapy programme accredited by one of the signatory Associations of the Mutual Recognition of Credentials Agreements (2008).

I declare that I understand and meet this requirement

Employment Details

If you are not currently working you may leave Employer Name and Employer Address empty.

Employer

Employer Address

Date of commencement of this employment

Hours of work per week in the year previous

Sectors working in

District Health Board

Other Health Organsiation (not DHB)

MOE - Special Education

School

Private Practice

Charitable Trust

University

Other, Studying, Retired

Please expand on your other working sectors

Qualification Details

You must provide the details of your qualification to register. If you are a first time student you can leave this field blank. If you have previous qualifications please enter these below.

SLT Qualification

University Attended/Attending

Year of Qualification

Country Qualified in if not New Zealand

Other SLT Qualification

University Attended/Attending

University Attended

Year of Qualification

Country Qualified in if not New Zealand

Disclosure Details

Not completing your CPD log is a breach of the NZSTA Principles and Rules of Ethics and goes against the NZSTA Constitution, preventing you from being able to sign your membership declaration

Offences *

Have you ever been convicted of a criminal offence or an offence related to the practice of speech language therapy?

Yes No

Please expand on your offences

Professional Practice *

Have you been the subject of a finding of professional misconduct, incompetence or incapacity by your employer or any other body?

Yes No

Please expand on your disciplinary proceedings

Disciplinary *

Have you ever been disciplined or sanctioned, or are there any disciplinary proceedings pending against you before any professional association, professional licensing authority or board, or other professional regulatory body?

Yes No

Please expand on your disciplinary proceedings

NZSTA Principles and Rules of Ehtics

Rules of Ethics *

I declare that I have read and understand all the NZSTA Principles and Rules of Ethics and agree to abide by all the standards required to maintained membership.

I declare that I understand and meet this requirement

Public *

I understand that, one I become a member for the year ahead, my membership status may be made available to the public.

I declare that I understand and meet this requirement

Thanks!

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