2009 Conference Proposal Form

The National Association for Rural Mental Health 35th Annual Conference Proposal Form

The lead presenter is responsible for forwarding information to co-presenters. Presenters are encouraged to register for the conference and are responsible for their own registration fees, travel and hotel arrangements and fees.

Please indicate the primary role for each presenter: Clinician, Administrator, Junior Researcher (not beyond the post-doc by 7 years), Senior Researcher, Consumer or Other (please specify).

We will continue to accept proposals for the conference until the agenda is filled.

Lead Presenter
*First Name:
*Last Name:
Credentials:
Lead Presenter Role:
If other please specify:
*Address:
*City:
*State:
*Zip Code:
*Phone Number:
*Email:
Affiliation:

Co-presenter #1
First Name:
Last Name:
Credentials:
Role:
If other please specify:

Co-presenter #2
First Name:
Last Name:
Credentials:
Role:
If other please specify:

Co-presenter #3
First Name:
Last Name:
Credentials:
Role:
If other please specify:

Co-presenter #4
First Name:
Last Name:
Credentials:
Role:
If other please specify:

Presentation Format

*Proposal is for: Paper Workshop Panel/RoundTable Poster

*Focus area(2) addressed: #1 #2 #3

*Title of Presentation

*Learning objectives:

1.
2.
3.

*Short Description of for Conference Program (30 words or less):

*Abstract (500 words or less):