Form 1 GMH Conference Registration Form

NIMH Global Mental Health Conference Registration

OMB # 0925-0740

Expiration Date: 05/2019

Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0740).  Do not return the completed form to this address.

(CONFERENCE TITLE)

(EVENT DATE)

(EVENT LOCATION)

Sponsored by the National Institute of Mental Health (NIMH) and Grand Challenges Canada

Registration

To register for the workshop on (EVENT DATE), please provide the information requested below. You will receive a confirmation e-mail from (ORGANIZING COMMITTEE EMAIL) following your submission of this completed online form. Registration will close when the available spaces are filled.

There is no registration fee and no on-site registration. Workshop participants are responsible for paying for their airfare, lodging, and all other costs associated with attendance at the workshop.

Note: Please do not register if you are a speaker or if you already have received an e-mail from the organizing committee confirming your attendance at the workshop. If you are unsure whether you need to register, please contact (ORGANIZING COMMITTEE EMAIL).

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Contact Information

• denotes required information

First Name •:

Last Name •:

Title •:

Organization •:

Degree•:

Career level •:

Gender:

Street Address •:

Suite I Apt I Box City •:

State/Province/Region •:

Zip/Postal Code •:

Country •:

Phone (include country code if you are an international participant) •:

Email address •:

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Visa Assistance

For international attendees requiring visa assistance, please contact (ORGANIZING COMMITTEE EMAIL) as soon as possible.

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Accommodations

Individuals with disabilities who may require sign language and/or reasonable accommodation to participate in this workshop should contact (ORGANIZING COMMITTEE EMAIL). Requests should be made at least 10 days in advance of the workshop.

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Lunch

Advance orders for lunch are recommended, as the on-site cafeteria lines can get long. Lunch pre-orders are available through (CATERING COMPANY WEBSITE).

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