Form 1 Joint Alliance-Coalition for Research Progress Meeting R

OMB #0925-0740

Exp date 7/31/2022

NIMH Joint Alliance-Coalition for Research Progress Meeting

Registration Form

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DATE & TIME

Monday, October 5, 2020

Time 10:00 AM – 5:00 PM EDT

LOCATION

The Bethesdan Hotel

8120 Wisconsin Avenue

Bethesda, Maryland 20814

DESCRIPTION

The 2020 NIMH Joint Alliance-Coalition for Research Progress Meeting will bring together representatives of national advocacy groups (Alliance for Research Progress) and professional organizations (Professional Coalition for Research Progress) with an interest in mental health research. This event is a unique opportunity to engage leadership from these groups and the NIMH to share the latest research advances and related developments; to foster dialogue on future directions of NIMH-funded research and priorities; and, to strengthen connections among participating organizations and encourage networking.

Registration

Please provide the information requested below to register for the 2020 NIMH Joint Alliance-Coalition for Research Progress Meeting. Only one participant per organization can register and attend, due to space limitations. A confirmation email will be sent to the email address provided following submission of this form. Online registration is available until September 4, 2020. On-site registration will be available thereafter.

* Indicates required information.

Your Contact Information

• First Name *:

• Last Name *:

• E-mail Address *:

• Phone *:

Your Work Information

• Job Title *:

• Company/Organization *:

• Street Address *:

• Suite / Apt / Box:

• City *:

• State*:

• Zip *:

• Country*:

What is your affiliation with NIMH? *

• Alliance for Research Progress

• Professional Coalition for Research Progress

• Other:

Badge Information

Badges will be made for all registered attendees. Please enter your name and the name of your organization as you want them to appear on your badge.

• Name:

• Organization:

Breakout Sessions

During the 2020 NIMH Joint Alliance-Coalition Meeting, there is a planned opportunity for a breakout session, “Mental Health and Pandemics: Challenges, Solutions, and Lessons Learned.”

Please rank your breakout topic choice in order of preference, with “1” being the topic you would most prefer to attend; we will do our best to accommodate preferences and will work to ensure representation of Alliance and Coalition groups in each session:

• Telemedicine

• Underlying mental health disorders

• Disparities

Travel Expenses

All travel-related expenses for this meeting must be paid by the registrant or the registrant’s organization.

Special Accommodation

Individuals with disabilities who may require sign language interpreters and/or reasonable accommodation to participate in this meeting should indicate the requested accommodation in the space provided below. Requests should be made at least 10 days in advance of the meeting.

I request the following accommodation(s):

Waiver

Please accept this waiver in order to register for the event.

I authorize the 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 (EVENT NAME). The recordings may be used for NIH for 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 to the above Waiver

Contact: [email protected]