Resignation from ACSLPA

Contact Information*

First Name
Entering your name above and submitting this form, authorizes ACSLPA to
process this status change.
Last Name

Email*

Registration Number*

Registration Number

Date*

Date Status Change is required

Profession

Audiologist
Speech-Language Pathologist

Reason for request;*

Temporary leave
Retiring
Moving out of province
Leaving the profession
Other

Declarations

As a regulated professional, bound by ethical and professional obligations, I confirm and do solemnly declare that:*

My contact, employment and professional liability insurance coverage information, as provided to ACSLPA via the member portal, is current and accurate as of the date of submitting this declaration (If no, do not submit this declaration. If you are uncertain that your information is correct, please log into your portal and return to this declaration once complete. ACSLPA staff will use this information in order to process your status change and it must be correct).

As of effective date of resignation, I further confirm and do solemnly declare that:*

I am not actively engaged in the practice of speech-language pathology or audiology as regulated under the Health Professions Act in Alberta (see below).alth Professions Act in Alberta (see below).
I agree that I cannot, and will not, continue to use my professional title or engage in the practice of speech-language pathology or audiology once my cancellation is in effect.
I understand and acknowledge that despite cancelling my registration, I continue to be subject to Part IV of the Health Professions Act, specifically that a complaint could be initiated against me relating to my past conduct as a regulated professional for a period of two (2) years.
I agree to immediately notify ACSLPA in writing if I intend at any time to return to active practice. I further understand and acknowledge that the ACSLPA Registrar or Registration Committee may require me to comply with any conditions that they may set prior to allowing me to resume the practice of speech-language pathology or audiology in Alberta.

HPA – Schedule 28 - Practice of Speech-Language Pathology and Practice of Audiology

Practice
3(1) In their practice, speech-language pathologists do one or more of the following:

(a) assess, diagnose, rehabilitate and prevent communication and oral motor and pharyngeal dysfunctions and disorders,

(b) teach, manage and conduct research in the science and practice of speech-language pathology, and

(c) provide restricted activities authorized by the regulations.

3(2) In their practice, audiologists do one or more of the following:

(a) assess auditory and vestibular function and diagnose, rehabilitate, prevent and provide appropriate devices and treatment for auditory and vestibular dysfunction,

(b) teach, manage and conduct research in the science and practice of audiology, and

(c) provide restricted activities authorized by the regulations.

ACSLPA staff will contact you within 2 - 4 business days to confirm your submission.

Member
Information

Key College Documents

Continuing Competence Program

Registration Renewal

Communications

Forms

Virtual Care

Practice Resources

Please complete the form below if you will no longer practice in your profession in Alberta.