1 OPP Annual Meeting- Sponsored Participants Registration

NIMH Outreach Partnership Program Annual Meeting Registration

OMB # 0925-0740

Expiration Date: 05/2019

Public reporting burden for this collection of information is estimated to average 10 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.

Sponsored Participant Registration Data

Please complete the information below:

First Name:

Middle Name:

Last Name:

Title [Please include your full position]:

Employer [Company, affiliation, etc.]:

Affiliations:

Address:

Address Line 2:

City:

State:

Zip Code:

Country:

Telephone:

Extension:

Badge Name:

Email Address:

Special Requirements

Please provide any special requirements related to the Americans with Disabilities Act:

Do you need a sign language interpreter?

Travel Support

Please select whether you need travel support.

[ ] I do not require travel support and will make my own arrangements.

[ ] I do require travel support.

[ ] I plan to drive.

Lodging

On behalf of NIMH, [contractor] will cover the cost of up to three (3) nights’ room and tax at the [hotel] for your participation in this meeting. NIMH will begin cover lodging on [date]. Please indicate your arrival and departure dates.

Arrival date:

Departure date:

Type of room:

[ ] I do not need lodging

Photo Release Information

I authorize National Institutes of Health to record and/or broadcast interviews, films, recordings, or photographs of me taken with my knowledge and in agreement with the NIMH Outreach Partnership Program Annual Meeting. The recordings may be used for NIH for the development, promotion, and broadcast or distribution in any medium or science, health, or educational programming. NIH is entitled to edit, copy, adapt, or translate the contribution and authorize others to do so in connection with NIH projects.

[ ] I Agree

[ ] I Disagree