Five Year Renewal Form Board Certification as a Child Language Specialist must be renewed every five years. To maintain Board Certification, complete and submit this form verifying that you have met the requirements specified in the Manual of Policies & Procedures.Name and Credentials (as you would like it to appear publicly)(Required) Name of Employer(Required) Address of Employer(Required) Street Address City State / Province / Region ZIP / Postal Code ASHA #(Required) Initial(Required)I am maintaining documentation of my completion of 100 hours of intermediate- or advanced-level continuing education in child language within the past five years should I be audited. (initial required below)Work Email(Required) Work Phone(Required)Home Address(Required)(for records purposes only) Street Address City State / Province / Region ZIP / Postal Code Personal Email(Required) Home Phone(Required)Cell PhoneCheck the activities related to child language in which you participate.(Required) Assessment Treatment Consultation Administration Teaching Supervision Research Volunteer Service Mentorship Other By payment of your annual fee and submission of this completed Five-Year Renewal Form, you affirm that you have met all requirements for Board Certification in Child Language renewal and verify that your Certificate of Clinical Competence is active.Applicant e-Signature(Required)Date(Required) MM slash DD slash YYYY Five Year Renewal Fee(Required)Total CAPTCHA
