2021 Kentucky Advocacy Network Application

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If you have any questions or concerns please feel free to contact Lacey Back at lacey.lane@kedc.org
Deadline April 14, 2021

First and Last Name *

5 DIGIT KSHA membership identification number *

Address *

The contact address provided is my: *

Home

Place of Work

Other

Daytime Phone Number ex. (xxx) xxx-xxxx *

Evening Phone Number ex. (xxx) xxx-xxxx *

Mobile Phone Number ex. (xxx) xxx-xxxx *

Years of KSHA Membership *

Certification *

Audiology

Speech

Dual Certificaiton

Describe your goals as an advocacy leader in your profession. *

By checking YES in the box below I acknowledge that if I am selected to participate in the Kentucky Advocacy Network (iKAN) I agree to fulfill all program requirements including: four online webinars and completing all pre and post workshop activities. I also acknowledge that my participation in all of the required components of the program is critical to the success of the program.

YES

Submit

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