2008 Proposal Form

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The National Association for Rural Mental Health 34th 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).

LEAD PRESENTER

Lead Presenter:
Credentials:
Lead Presenter Role (choose one):

Clinician	Administrator	Junior Researcher (not beyond the post-doc by 7 years)
Senior Researcher	Consumer	Other (please specify):
Organization:
Address:
City: State: Zip:
Phone: Fax: Email:

CO-PRESENTERS

Co-Presenter#1:
Credentials:
Co-Presenter Role (choose one):

Clinician	Administrator	Junior Researcher (not beyond the post-doc by 7 years)
Senior Researcher	Consumer	Other (please specify):

Co-Presenter#2:
Credentials:
Co-Presenter Role (choose one):

Clinician	Administrator	Junior Researcher (not beyond the post-doc by 7 years)
Senior Researcher	Consumer	Other (please specify):

Co-Presenter#3:
Credentials:
Co-Presenter Role (choose one):

Clinician	Administrator	Junior Researcher (not beyond the post-doc by 7 years)
Senior Researcher	Consumer	Other (please specify):

Co-Presenter#4:
Credentials:
Co-Presenter Role (choose one):

Clinician	Administrator	Junior Researcher (not beyond the post-doc by 7 years)
Senior Researcher	Consumer	Other (please specify):

Proposal is for: Paper Workshop Panel Roundtable Poster
Focus Area(s) Addressed: #1 #2 #3 #4 #5
Title of Presentation:
Learning Objectives (list three): 1) 2) 3) Short Description of for Conference Program (30 words or less): Abstract (500 words or less):

Presenters will be notified of acceptance by January 15, 2008.