Application Form

The Hendricks County Mental Health Association is organizing a Speakers Bureau of MHA representatives to present educational information on mental health topics and issues to community and civic groups and organizations in Hendricks County and for our MHA sponsored Community Education Programs available to the public. If you would like to be a part of this effort by sharing your talents, experiences, and information with others, please complete the following form and return it to the Mental Health Association (see address above). Questions can be addressed to the MHAHC office at 317-272-0027 from 9:00 A.M. to 4:00 P.M. or leave a message if needed. Your involvement would be most welcome!

NAME _______________________________________ Current Date __________

ADDRESS (Home)__________________________    City ____________   ZIP ______   Phone ________

ADDRESS (Bus.) ___________________________  City ____________    ZIP ______   Phone ________

DAY TIMES YOU ARE UNABLE TO SPEAK

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PREFERRED LENGTH OF PRESENTATION TIME

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MENTAL HEALTH TOPICS / ISSUES YOU FEEL QUALIFIED TO PRESENT 

___________________________________________________________________________________

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Please complete above and return to:

M.H.A.H.C  75 Queensway Dr - Suite A, Avon, Indiana 46123

© 2005 Mental Health America of Hendricks County  All Rights Reserved