WSHA/Viterbo University Graduate Credit Form

Please check the appropriate information to validate your attendance at each session of the WSHA Convention/course. Use the space below the session to indicate the title/presenters for each session you attend, what you have learned from the session and related it to the readings you select. You may attach additional pages, if necessary to support your findings.

FIFTEEN HOURS OF ATTENDANCE IS REQUIRED. YOU MUST ATTEND FULL SESSIONS TO COUNT HOURS.

THURDAY, FEBRUARY 4, 2016 (PRECONVENTION SESSIONS)

AFTERNOON SESSION: (1:30 – 4:30 p.m.) Please list session attended

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EVENING SESSION: (5:30 – 8:30 p.m.) Please list session attended

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FRIDAY, FEBRUARY 5, 2016

(7:30 – 9:00 a.m.) Legislative Update (counts as ONE hour)

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BLOCK 1 (10:00 am - 12:00 pm) Various sessions offered. Please note session(s) attended and time of session(s) attended.

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LUNCH 12-1:00 in Exhibit Hall (NO CREDIT HOURS)

BLOCK 2 (1:15-3:15 p.m.) Various sessions offered. Please note session(s) attended and time of session(s) attended.

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BLOCK 3 (3:45 - 5:45 p.m.) Various sessions offered. Please note session(s) and time of session(s) attended.

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SATURDAY, FEBRUARY 6, 2015

WSHA Association Breakfast and Leadership Presentation

(7:30 – 9:30 a.m.) COUNTS AS ONE HOUR

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GENERAL SESSION: Ethics Presentation: Dealing with Ethical Dilemmas in the Workplace. 9:30 – 11:30 a.m.

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GENERAL SESSION: Improving Your Practice and LUNCH 11:30 – 12:45 (one hour)

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BLOCK 4 – 1:00 – 3:00 various sessions offered. Please note session(s) and time of session(s) attended.

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BLOCK 5 (3:00 – 5:00 p.m.) Various sessions offered. Please note session(s) attended and time of session(s).

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This form must be turned in to a WSHA representative on Saturday, February 6, 2016 at the end of the convention/course OR it may be mailed to the instructor for this course: Kate Morand; PhD, CCC-SLP; 453 North Baldwin Street; Madison, WI 53703. The instructor must receive this form no later than Saturday, March 12, 2016. Please DO NOT email this form to the instructor; paper submissions only will be accepted. Please do not send the form via certified mail. If you want confirmation that your paper was received, please include your email address below and a note requesting confirmation, and an email confirming receipt will be sent by the instructor. The instructor will review this form for validation of hours and quality of content based on the grading rubric received at students’ registration.

By my signature I validate my attendance and participation as noted above.

SIGNATURE______

Date______

Print Name______

Address______

City______State______Zip______

Phone______

Email______

Wisconsin Speech-Language Pathology and Audiology Association

563 Carter Court – Suite B

Kimberly, WI 54136

(920) 560-5642 phone • (920) 882-3655 fax •