Form 1 2019 OPP Registration Form and Questions

NIMH Outreach Partnership Program Annual Meeting Registration

OMB # 0925-0740

Expiration Date: 05/2019

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2019 OPP Annual Meeting Registration Questions

Registration Questions:

Title (Please include your full position):

Employer (Company, affiliation, etc.):

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Country:

Telephone Number:

Telephone Extension Number:

Cell Phone Number:

Email Address:

Badge Information

Badges will be made for all registered attendees. Please enter the name you want to appear on your badge as well as the organization you are representing. Please note, due to the limited number of character spaces, organization names may be shortened.

Badge Name:

Badge Organization:

Special Requirements

Do you require any special aids or services? Pursuant to the Americans With Disabilities Act of 1990 and ADA Amendments Act of 2008, discrimination against people with disabilities is prohibited by law. We will adhere to ADA requirements for reasonable accommodations for those with special needs.

None

Visual

Audio

Mobile

Other

Please provide additional details regarding any accommodation you may require:

Do you need a sign language interpreter?

Yes

No

Travel Agency Support – Sponsored Participants/Sponsored Presenters

The Bizzell Group will cover all travel arrangements, including airline and rail tickets. In accordance with the Federal Travel Regulations (FTR), only participants who live more than 50 miles from the meeting site will be provided transportation and lodging. Bizzell will make every effort to accommodate your requests in accordance with the FTR by providing economical, coach class non-refundable tickets. Rail tickets can be provided to participants for whom air transportation is not a practical or reasonable option.

We have a dedicated travel agency that is available to assist in finding the best travel rates possible. Do you need assistance in making travel plans?

I do require travel agency support

I live within a 50-mile radius of the conference location and plan to drive or take public transportation

I will make my own travel arrangements and will contact Longevity to confirm the reimbursement process and amount for my trip

Lodging – Sponsored Participants/Sponsored Presenters

On behalf of NIMH, The Bizzell Group will cover the cost of up to two (2) nights’ room and tax at the DoubleTree by Hilton Hotel Bethesda for your participation in this meeting. NIMH will begin covering lodging on July 30, 2019. Please check all the dates in which you will be staying at the hotel.

Tuesday, July 30, 2019

Wednesday, July 31, 2019

I will need additional nights lodging and will contact Bizzell to confirm the nights and payment process at

I do not need lodging

What type of room would you prefer?

Single

Double

Wheelchair Accessible

Speaker Materials– Sponsored Presenters

NIMH plans to make all speaker presentations available for distribution before 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 this by checking one of the boxes to the right.

I grant permission to NIMH to distribute my presentation

I do not grant NIMH permission to distribute my presentation

I will provide an alternate presentation that can be distributed

Speaker Materials– Non-sponsored Participants

NIMH plans to make all speaker presentations available for distribution before 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 this by checking one of the boxes to the right.

I grant permission to NIMH to distribute my presentation

I do not grant NIMH permission to distribute my presentation

I will provide an alternate presentation that can be distributed

I am not a speaker

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