1 OPP Annual Meeting- Non-Sponsored Participants Registrat

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 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.

Non-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?

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

Speaker Materials

NIMH plans to make all speaker presentations available on a file sharing website for distribution after the meeting. The presentations will be saved in a format which does not allow alteration (i.e., pdf format) and you will be properly credited and cited as the author of the presentation. Please let us know if you agree to do this by checking one of the boxes below.

[ ] I grant permission to NIMH to post my presentation.

[ ] I do not grant NIMH permission to post my presentation.

[ ] I will provide an alternate presentation that can be posted.

[ ] I am not a speaker.