2020 Expression of Interest - The Brigid Rivoire Award for Champions of Agricultural Mental Health

Expression of Interest form

Question Title

* 1. Nominee

Name of the organization or individual:

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* 2. Name of the specific nominated initiative:

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* 3. Mailing Address:

Street Address:

Address Line 2:

City:

Province:

ZIP / Postal Code:

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* 4. Phone:

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* 5. Fax:

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* 6. Email:

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* 7. Website:

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* 8. Name and title of primary contact:

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* 9. Type of initiative: See Appendix A for a brief description of each category and relevant criteria.

Community Capacity Building

Workplace Initiative

Research Project

Social Innovation

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* 10. Duration of the Initiative

Starting date

Date

End date (If applicable)

Date

Question Title

* 11. Provide a basic description of this initiative: How is it linked to agricultural mental health? What is its core purpose, target population, and what primary activities are undertaken to achieve these? (200 words)

2020 Expression of Interest - The Brigid Rivoire Award for Champions of Agricultural Mental Health

Expression of Interest form

Question Title

* 1. NomineeName of the organization or individual:

Question Title

* 2. Name of the specific nominated initiative:

Question Title

* 3. Mailing Address:

Question Title

* 4. Phone:

Question Title

* 5. Fax:

Question Title

* 6. Email:

Question Title

* 7. Website:

Question Title

* 8. Name and title of primary contact:

Question Title

* 9. Type of initiative: See Appendix A for a brief description of each category and relevant criteria.

Question Title

* 10. Duration of the Initiative

Question Title

* 11. Provide a basic description of this initiative: How is it linked to agricultural mental health? What is its core purpose, target population, and what primary activities are undertaken to achieve these? (200 words)

* 1. Nominee

Name of the organization or individual: