Temporary SLP-Assistant Registration Form

Cost: $40 (+$3 for PayPal)

THIS FORM MAY ONLY BE COMPLETED BY THE SLP REQUESTING THE BELOW LISTED SLP ASSISTANT BE ADDED TO THEIR LICENSE. THIS FORM MAY NOT BE COMPLETED BY ANOTHER SLP, SLP-ASSISTANT, OR OFFICE STAFF.*

BY SIGNING I CERTIFY THAT I, THE POTENTIAL SUPERVISING SLP FOR THIS REGISTRANT IS COMPLETING THIS FORM AS REQUIRED BY ARTICLE 22. IF THIS FORM IS NOT SIGNED PROPERLY, IT WILL BE DENIED.

I the potential primary supervising SLP have held a full, unrestricted, permanent license for two years, and I have at least one year of experience supervising an SLP-Assistant*

If the Assistant has not been registered with the NC Board they will need to fill out the Assistant Application.

I affirm and understand

Supervisor Information

Primary Supervisor*

Prefix First Middle Last

NC License Number*

How many SLP-Assistants do you currently supervise?*

This should include all SLP-Assistant(s) that you supervise, including under other licenses/registrations you may hold in other jurisdictions. This also includes if you are the secondary supervisor for any SLP Assistant(s).

None
One
Two or more

Primary Supervisor Email*

This email address will be used to send the primary supervisor instructions and a link to the required Performance-Based Competency Assessment & Orientation Checklist.

How many SLP-Assistants does this licensee currently supervise?*

This should include all SLP-Assistants that they supervise, including under other licenses/registrations you may hold in other jurisdictions. This also includes if they are the secondary supervisor for any SLP Assistant(s).

None
One
Two or more

Assistant Information

Name*

Prefix First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone*

Work Phone

Email*

Employer Information

Employer Name*

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Service Locations*

Provide the exact location where the Assistant will provide services. Complete names and addresses are required for businesses, schools, Head Start Programs and daycares. If providing services in homes, please provide the city and/or county in which the homes are located.

Street Address Address Line 2 City State ZIP Code

Are there multiple locations where services will be provided?*

Yes
No

Additional Locations*

Please list any additional locations where services will be provided. Complete names and addresses are required for businesses, schools, Head Start Programs and daycares. If providing services in homes, please provide the city and/or county in which the homes are located. For those cases please state they are home locations in City/County.

Academic Information

Academics*

Training Program	Major	Degree	Date

SLP-Assistant Exam Date

Please select the date the exam was passed by the applicant, if they have taken their exam.

OTC Hearing Aids and "Prescription" Hearing Aids Resource Page view page

Step 1 of 4

Cost: $40 (+$3 for PayPal)

Supervisor Information

Assistant Information

Employer Information

Academic Information

Quiz

Assistant Protocol Target Behavior Form

Supervisor & Assistant Consent & Signatures

To be completed by the Assistant

To be completed by the Supervisor

Notice

Upon Submission

Payment Information

Instructions: Mail in form with Payment