autmn update 2015
DESCRIPTION
ÂTRANSCRIPT
WELCOME TO A NEW YEAR forAustralian Rotary Health and to my firstcontribution to our newsletter asChairman. Welcome also to our newBoard, where continuing directorsLaurie Barber, Russ O’Malley (ViceChairman), Greg Ross, Peter Williams,and myself are joined by incomingdirectors Phil Armstrong, Graeme
Davies, Kevin Shadbolt, Colin Thorniley and BarbaraWheatcroft. Our sincere thanks to our outgoing directors,Past Chairman Terry Grant, Phil Cordery, John Egan,Barney Koo and Dick Wilson for their considerablecontributions over several years to Australian RotaryHealth. Their insights will be missed.
RI InstituteSince our AGM in Sydney in October, Australian RotaryHealth participated in the joint Australia-New ZealandRotary Zone Institute in Wellington in early December,which involved our annual DGN cocktail party, a full houseARH Dinner, followed by our Report to Institute. It wasencouraging to have an excellent attendance at the functionsand meeting with a lot of interest and support shown for theongoing work of Australian Rotary Health.
Christmas DinnerEvents since then have included the ARH ChristmasFunction held at The Epping Club in Sydney on 10December 2014, which was a magnificentshowcase of the work of a number of ourcurrent researchers on the subject of theirARH research grants and scholarships, aswell as the very successful ARH CharityGolf Day again held at Riverside Oaks on25 February 2015.
In Memory of Geoff Betts & Geoff BaileyOn a sadder note, ARH has lost two of itsmost influential contributors with therecent passing of Geoff Betts and GeoffBailey in February and March.
PDG Geoff Betts AM, MBE of the Rotary Club ofGeelong, was a foundation member of ARH, served as Vice-Chairman 1983-1988 and was ARH’s second Chairmanfrom 1988-1991. There is no question that his efforts on theorganisation’s behalf established the framework and laid thefoundations for the continuing role of Australian RotaryHealth in supporting medical research to the benefit of allAustralians.
PDG Geoff was awarded Life Membership of AustralianRotary Health in 1991. The Geoffrey BettsPostdoctoral Fellowship has also been named in hishonour. His passion and commitment in supportof Australian Rotary Health have been fundamentalto the ongoing success of the organisation thatAustralian Rotarians value so much.
PP Geoff Bailey OAM, of the Rotary Club ofMitcham, SA, was the instigator of the ARHIndigenous Health Scholarship program establishedin 2000. This has proven to be one of the mostsuccessful programs of ARH, with almost 200Indigenous scholars having graduated into theworkforce with another 20 expected to be...
From our New Chairman
Continued page 2
Australian Rotary HealthSupporting healthier minds, bodies and communitiesthrough research, awareness and education
AUTUMN UPDATE 2015
Australian Rotary Health • PO Box 3455 Parramatta NSW 2124 • Phone 02 8837 1900 • [email protected]
Associate Professor Felice Jacka, Deakin University as ARHChristmas Dinner guest speaker with ARH Director M.C. Greg Ross
The late PDG Geoff Betts AM, SecondChairman of ARH
Jeff Crofts
2 Australian Rotary Health • PO Box 3455 Parramatta NSW 2124 • Phone 02 8837 1900 • www.australianrotaryhealth.org.au
ARH UPDATE
...graduating this year. PP Geoff wasrecognised with the award of theAustralian Rotary Health Medal in2013 for his dedication and passion forClosing the Gap on Indigenous health.Both Geoff ’s leave a significant legacyto ARH for the benefit of allAustralians.
2016 FundingThe Board has decided to commit anamount in the order of $1,900,000 forMental Health Research Project Grants– Mental health of Young Australians- in 2016 to cover ongoing committedresearch grants only, in addition to ourusual funding (in the order of$500,000) for all other ARHresearch/scholarship programs for2016. This decision was made inconsideration of the extent of longerterm research grants currently beingundertaken and the low probability ofsuccess for potential new applicantsgiven the limited research grant funds
that would otherwise have beenavailable in 2016. The Board feels thatthese decisions will achieve the bestpossible research outcomes for ARH’sfunds in the longer term.
Commonwealth support forIndigenous ProgramI am also pleased to confirm that theCommonwealth Government hasrenewed its support for the ARHIndigenous Health Scholarshipprogram for 2015, at the same level offunding as 2014. In addition, ARHhas now secured funding from theQueensland State Government for2015 for 4 Indigenous Scholars. Thisis the first time that Queensland hasbeen involved with the ARHIndigenous Health Scholarshipprogram, and it now joins SA, NSWand Victoria as a provider of funds.
None of the achievements of ARHcould be attained without the efforts
of our dedicated and committed staffunder the leadership of CEO JoyGillett – my continuing thanks to Joyand the entire team (Terry Davies,Cheryl Deguara, Jenny Towe, BridgetMoore, Steff Fenton, MaddisonHancock) on behalf of us all.
Rotary InternationalIn closing, I acknowledge that manywould be aware that for the past year,ARH has been endeavouring toformalise its relationship with RotaryInternational. While I am unable toadvise a final outcome at this time, Iam pleased to confirm that we arecurrently engaged in positive andconstructive discussions with RI staffin Evanston. I remain optimistic thatwe will shortly achieve a resolutionsatisfactory to all parties, which willcontinue to recognise ARH as a projectof the Rotary districts of Australia.
Jeff Crofts, ARH Chairman
PDG Phil ArmstrongPhil joined the RotaryClub of Moruya, NSW,in 2000 and is a currentmember. He is a past“Peace” Governor ofDistrict 9710 servingon “Team Tanaka”.Phil’s ties to Rotary go back to his Father’smembership of both the Temora andGoulburn Mulwaree Clubs of NSW in the1960’s, as well as his own membership ofRotaract in the 1970’s. Phil and his wifeKim are Companion supporters of ARH.
PDG Graeme DaviesGraeme joined theRotary Club of Griffith,NSW, in 1991 and isPast President of theClub. He is a currentmember and PastPresident of the RotaryClub of Kincumber, NSW. Graeme andhis wife Lyn were long term members ofDistrict 9670's Rotary Youth ExchangeCommittee. He is a past member of the
District 9685 ARH Committee and is PastDistrict Governor for D9685. He iscurrently District 9685 Club Extensionofficer, and a Paul Harris Society member.
PDG Kevin ShadboltKevin joined theRotary Club ofLatrobe, Tasmania, in1985, he is a PastPresident and currentmember. He is PastDistrict Governor ofD9830 in both 2003-04and 2007-08. Kevin was a FoundationChairman, District Trainer and GroupStudy Chairman. He initiated Districtinvolvement in Fiji low-cost Shelters, wasthe Chairman of International ProjectDevelopment as well asserving on a widevariety of club andDistrict committees.
PDG Colin ThornileyColin joined theRotary Club Heirisson,
WA in 1977 after being a Group StudyExchange team member in 1975, and is acurrent member. He is a Benefactor ofthe Rotary Foundation. Colin is currentlyan Assistant Coordinator for part ofRotary Zone 8, a Past District 9455Governor, past Group Study ExchangeTeam Leader to San Francisco in 1992.He has been the Chair of many DistrictCommittees.
PDG Barbara WheatcroftBarbara joined theRotary Club ofHindmarsh, SA, in2004 is Past Presidentand Past Treasurer.She joined the RotaryClub of AdelaideParks, SA in 2010when the Rotary Club of Hindmarshreturned its Charter. Barabara wasSecretary of the District GSECommittee from 2007 to 2009 and Chairfrom 2009 to 2010. Barbara is PastDistrict Secretary and Past DistrictGovernor.
Meet our New Directors
From our New Chairman Continued from cover
3Australian Rotary Health • PO Box 3455 Parramatta NSW 2124 • Phone 02 8837 1900 • www.australianrotaryhealth.org.au
AUTUMN 2015
Australian Rotary Health premieredtheir new Australian Rotary HealthMovie in January, 2015. The videoexplores four inspiring people,supported by Australian RotaryHealth, who are now changing theircommunities in various amazingways.
Part 1: Australian Rotary Health gaveFay Jackson a launch pad to fulfill herpassions in helping people living withmental ill-health to succeed in theworkplace.
Part 2: An Indigenous scholarshipfrom Australian Rotary Healthsupported Dr. James Charles to
complete his degree at university andbecome South Australia’s firstIndigenous podiatrist.
Part 3: Professor Jane Pirkis receivedAustralian Rotary Health researchfunding crucial to the development ofguidelines in preventing ‘copycat’suicides, among other suicideprevention initiatives.
Part 4: Australian Rotary Healthallowed Betty Kitchener AM to gatherenough information to develop theMental Health First Aid (MHFA)course.
Download the new Australian Rotary
Health Movie from our website toshow at your next Club meeting, find itat www.australianrotaryhealth.org.au >About > Promotional Video 2015
Movie Premiere
Awarding Gratitude
Life MembershipTerry Grant was awarded the mostprestigious ARH award, LifeMembership. In recognition of his 3years as Chairman and previous 4years as a Director. PDG Terry, amember of the Rotary Club ofSunbury, Victoria, brought energy,passion and a new vision for ARHand we congratulate and thank him.
ARH MedalPDG Bob Aitken was awarded thesecond ARH Medal in 2014 for hiscontribution over 25 years to thepromotion and public image of ARH
through all media resources,including Rotary Down Under. Bobwas presented with the award at theARH Christmas Dinner and joins co-recipient for 2014, HonoraryMember Dean Brown.
District Achievement AwardDistrict 9675 received the DickWhite District Achievement Awardfor the introduction of the ARHGolden Microscope Award, theirsupport of Indigenous HealthScholarships throughout Australia,continued financial support ofnumerous Funding Partner PhD
Scholarships, and their generousgeneral support and donations toARH.
Award for KnowledgeDisseminationDr Lexine Stapinski from the Centreof Research Excellence in MentalHealth and Substance Use (CREMS)developed a series of school-basedprograms for adolescents (14yrs+)that have proven effective in delayingthe uptake of alcohol and drug use.In Term four 2014, every secondaryschool in Australia received aresource package.
Life MembershipARH Chairman Jeff Crofts and
recipient PDG Terry Grant
ARH MedalPast ARH Chairman Terry Grant
& CEO Joy Gillett with recipient Bob Aitken
District AwardD9675 DG Barry Antees accepts the award from
Past Chairman Terry Grant
Knowledge Dissemination AwardProfessor Bernhard Baune & Professor
Michael Sawyer, University ofAdelaide with award recipient
Lexinie Stapinski
4 Australian Rotary Health • PO Box 3455 Parramatta NSW 2124 • Phone 02 8837 1900 • www.australianrotaryhealth.org.au
On Australia Day, Ian Scott PhDScholar Michael De Santis wasawarded Wollongong’s YoungCitizen of the Year award for hischaritable and academicachievements. Michael helpsbring the Telstra Beach to BushProgram to students inpreschools, primary andsecondary schools. He is a CareersFair Presenter for the School of Medicine both in Wollongongand Sydney, and he volunteers for a number of charitable
organisations, including Surf LifeSaving.
Michael is funded by an Ian ScottPhD Scholarship to explore thepotentially detrimental long-termeffects of antipsychotic drugtreatment on the developing brain.His research will provide importantinformation to psychiatrists andpaediatricians to balance therisk/benefit ratio before prescribingantipsychotics to children andadolescents.
Mental Health Scholar - Young Citizen of the Year
ARH UPDATE
myCompass is the new internet and phone-based self-helpprogram for people with mild to moderate depression,anxiety or stress. Developed by researchers at the Black
Dog Institute, AustralianRotary Health is nowfunding its nextdevelopment – myCompassfor young people withdiabetes.
CEO Joy Gillett, ResearchManager Bridget Moore andMedia Manager Steff Fentonhad the opportunity ofmeeting with researchers fromthis project - Professor JudyProudfoot, Dr Janine Clarke,and Dr Veronica Vatiliotis.
The Digital Age of Mental Healthhelp-seeking
Rural Nursing Scholars, TraceyWilkinson and Anja Sweeney,presented at the Rotary Club of Sale,Victoria about their experience ofgraduate nursing year at the CentralGippsland Health Service in Sale.
“We have been able to consolidateupon our nursing knowledge, skills andpractices, within a supportedenvironment,” said Tracey.
“To the level where we are ready to be
fully fledged Registered Nurses andpursue the area of nursing in which wewish to spend our career.”
“We have a rare opportunity to giveback to our community and practiceour skills somewhere where a nurse hasthe unique chance to make a differencein the town or towns that meansomething to them personally. Beingable to care for our community hasbeen a rare and fulfilling experience,”Anja said.
Nurses like Tracey and Anja who aresponsored through the Rural NursingScholarship program will be the futurelifeblood of this healthcare service,making scholarships an investment insustaining quality rural healthcare.
Both Scholars extended great thanks totheir sponsors Mavis and Bill Jennings,the Rotary Club of Sale and AustralianRotary Health, as well as the CentralGippsland Health Service, and all whoattended the presentation meeting.
Australia Day Ambassador Lynne Williams, MichaelDe Santis and Lord Mayor Cr Gordon Bradbery
Rural Nurses visit Sale
THE PARRA AMBLE24th May, 2015
Part Treasure Hunt. Part Amazing Race. A fun event for EVERYONE - families, friends & corporate
groups - raising money for health research.
www.parra-amble.com
AUTUMN 2015
A new ANZAC PhD ResearchScholarship has been introduced byAustralian Rotary Health to ease therising incidence of post-traumaticstress disorder (PTSD) in war veterans.
The inaugural scholarship willinvestigate the link between commonphysical health symptoms to thedevelopment of mental illness.
“With an increasing number of warveterans being diagnosed with PTSD,we saw a need to invest in this specifickind of mental health research.” saidAustralian Rotary Health CEO JoyGillett OAM.
“As funding is secured, further PhDScholarships will be offered to researchPTSD in war veterans and theirfamilies.”
The inaugural ANZAC PhD Scholar,Kristin Graham, will be supported by$35,000 per annum for up to 3.5 years atthe Centre for Traumatic Stress Studies,University of Adelaide, South Australia.
Ms. Graham will use the largestdatabases recording the physical andmental health and wellbeing ofAustralian military personnel to identifypatterns in physical symptoms that areassociated with trauma-related mentalhealth symptoms, which have happenedover a 5 year period.
“Although physical symptoms are thereason for many personnel to seektreatment, these symptoms are oftenexplained by the psychiatric disordersassociated with combat exposure such asdepression and PTSD,” Ms. Grahamsaid.
ANZAC PHD Scholarship to Reduce PTSD
Over the years the Rotary Club ofAdelaide, SA, have encouraged theirmembers to become Companions ofAustralian Rotary Health. Toacknowledge the generosity of thesedonors, they created a banner whichlists all 33 Companions to date. Ifyou would like to become aCompanion of ARH please contactour office on 02 8837 1900.
Professor Glenn Bowes, Senior AssociateDean of the University of Melbourne,recently honoured Australian RotaryHealth with The Wilson Medal, presentedto CEO Joy Gillett. The Award recognisesthe major contribution of AustralianRotary Health to the University ofMelbourne through research funding andscholarships.
Our AdelaideCompanions
5Australian Rotary Health • PO Box 3455 Parramatta NSW 2124 • Phone 02 8837 1900 • www.australianrotaryhealth.org.au
Friday October 9 is
HAT DAYShining a light on Mental Health
www.hatday.com.au
Melbourne Uni Medal Recognises ARH Funding
ANZAC PhD Scholar, Kristin Graham
6 Australian Rotary Health • PO Box 3455 Parramatta NSW 2124 • Phone 02 8837 1900 • www.australianrotaryhealth.org.au
Golfing for Research
Since Hat Day on Friday October 10, we have beeninundated with success stories, photos and generous chequepresentations from our Hat Day supporters. A tremendous$166,000 was raised for mental health research and 100% ofdonations will go directly to this cause.
2014 was an exciting year for Hat Day, as we engaged withorganisations and the media to shine a light on mental illness.Australian Rotary Health was privileged to partner with theABC in their ‘Mental As’ Campaign, a week of programmingrelated to mental health.
Many of our mental health scholars and researchers becameHat Day Research Reps, discussing exciting research findingsin videos and blogs for a widespread social media campaign.They also took part in interviews for radio, television,newspaper, magazine and online news stories.
Hat Day will be held on Friday October 9, 2015.
www.hatday.com.au
Mental Health was Top of Mindon Hat Day!
Rotary Club of Kwinana, WA celebrate Hat Day
We have hosted two successful golf days since our lastNewsletter - Golf For Research at Twin Creeks GolfCourse, NSW on November 21, 2014, and the Annual ARHGolf Day at Riverside Oaks Golf Course, NSW, on February25, 2015. Together they raised $21,000 for mental healthresearch funding.
Australian Rotary Health’s Royal Melbourne Golf Day willbe held on Monday October 5, 2015. To play golf at Australia’snumber one course and support mental health research, pleasecontact Terry Grant on 0412 111 499.
2015EVENTSCALENDAR
SATURDAY MAY 23 - SUNDAY MAY 24BANISH THE BLACK DOG RIDE
A relaxed cycling tour promoted by the Rotary Club of TownsvilleCentral, Qld to raise awareness and funds for mental health.
www.everydayhero.com.au/event/Banishtheblackdogbikeride2015
SUNDAY MAY 24 ANZAC PARRA-AMBLE
ANZAC Parra-Amble To commemorate the ANZAC Centenary,ARH will run a family event in historical Parramatta, NSW.
All funds will support the new ANZAC PhD scholarshipresearching the post-traumatic effects of war.
See www.parra-amble.com
JUNE 8 – JULY 12RIDE TO THE OTHER SIDE
Craig Alford and the Rotary Club of Armadale, WA is ridingaround the country on a ride-on lawn-mower to raise funds
for ARH, so far covering 5,300km of the 15,000km. In their fourth stage, the team will cover 5,500kms from
Junee, NSW via Cairns, Qld. to Darwin, NTwww.ridetotheotherside.org.au
SUNDAY AUGUST 10CITY2SURF, SYDNEY, NSW
ARH will be entering a team of researchers, supporters and friends to run in this event. Find the ARH team on Everyday
Hero or contact the Office to join!
SUNDAY AUGUST 30NORTH RYDE FUN RUN
A fun run event in conjunction with Macquarie University, local businesses and the Rotary Club of North Ryde.
www.northrydefunrun.com.au
MONDAY OCTOBER 5MELBOURNE GOLF DAY
Play at the Royal Melbourne, Vic. Please contact Lee Strahan on 0414 751 959
FRIDAY OCTOBER 9HAT DAY
Host a Hat Day at your Club or workplace www.hatday.com.au
SUNDAY OCTOBER 11AUSTRALIAN ROTARY HEALTH WINE, FOOD &
MUSIC RACE DAYHeld at Hawkesbury Race Course, NSW.
FRIDAY NOVEMBER 13TWIN CREEKS GOLF DAY
Ambrose event held in Luddenham, NSW. See the ARH websitefor more, or contact the ARH Office on 02 8837 1900.
DATE TBC, DECEMBERSALLY’S RIDE TAMAR VALLEY CYCLE CHALLENGE
Sally Fletcher & the Rotary Club of Central Launceston run anannual Tasmanian ride to raise money for research into youth
suicide http://www.sallysride.com.au/
WEDNESDAY DECEMBER 9CHRISTMAS DINNER
Held at The Epping Club, NSW. Save the date to celebrate 2015 with us.
ARH UPDATE
Cycling Success Stories
Four bike rides have been held in our name alreadythis year. Bike rides are a wonderful initiativewhich we would love to see grow. They encouragepeople to get active, improving the mental healthof individuals involved, as well as raising vitalfunds for mental health research.
22 February: Tour de Norfolk PlainsTasmanian District 9830 and the Rotary Club ofLaunceston West engaged cyclists of all levels intheir community with a one day ride event whichraised funds for ARH. Cyclists chose from one ofthree ride lengths through the countryside justoutside Launceston; 23km, 55km or 102km.
14-19 March: ‘Hill or Two’ Ride to D9790ConferencePart of District 9790’s seventh Annual Ride toConference, cyclists took part in a circular ride of600kms over 6 days, beginning and ending inWangaratta. This year’s ride had 32 peopleinvolved, including one participant who swam51km over 6 days to raise funds and awareness. Theride was a great success with donations anticipatedto be around $15,500.
15-21 March: Ride for Research $$$sThe Ride for Research $$$s bike ride is one ofARH’s largest and longest-running annualfundraising events. Cyclists completed a circulartour this year starting and ending in Ballarat,Victoria - a total distance of 808.75kms over sixdays. Fifty seven cyclists, including 13 support crew,took part in the challenge. Ride for Research $$$s isan initiative of District 9810, which has raised$42,000 for ARH in 2015 so far, but donations arestill being tallied.
14-17 April: Glen to GoondiwindiRun by District 9640, Victoria, under the slogan‘Cycling for Mental Health’. Riders cycled 263kmin four days from Glen Innes, NSW toGoondiwindi, Queensland for their annual Ride toConference. Fundraising is still taking place andwill be used for rural mental health researchthrough ARH.
Healthy Photographers
In it’s third year running, the Australian Rotary Health PhotographyCompetition collected entries from all around Australia. Participantscaptured moments on camera to connect with the theme ‘Health andWellbeing of the Community’. Entries closed on ANZAC Day and willbe announced on the Photo Comp website in May, visitwww.australianrotaryhealthphotocomp.org or find them on Facebook.
7Australian Rotary Health • PO Box 3455 Parramatta NSW 2124 • Phone 02 8837 1900 • www.australianrotaryhealth.org.au
In continued success, 270 people attended the annual AustralianRotary Health Wine, Food & Music Race Day on Sunday October12, 2014. The event raised $33,000 from sponsorship, ticket salesand silent auction.
Racing for Research - Hawkesbury, NSW
AUTUMN 2015
Photo Credit: Choo Bang Chew
Photo Credit:Zoe Edins
8 Australian Rotary Health • PO Box 3455 Parramatta NSW 2124 • Phone 02 8837 1900 • www.australianrotaryhealth.org.au
Gold Companions - $10,000Stephen FisherRotary Club of Templestowe, Vic.Robert GardinerRotary Club of Blacktown City, NSW
Companions - $5,000Don Durie AMRotary Club of Lindfield, NSWLoloma & Colin PulsRotary Club of Horsham, Vic.Malcolm & Valerie HansenRotary Club of Campbelltown, SARon & Marilyn PearceRotary Club of Rosanna, Vic.Arthur Harris & Merilyn BeachRotary Club of Dural, NSWGraham LeeRotary Club of Adelaide, SATeresa EvansRotary Club of Walkerville, SARotary Club of Capalaba, Qld.
Diamond Friends - $2,500Pat SheehanRotary Club of Bendigo Sandhurst, Vic.
Platinum Friends - $2,000J MorganRotary Club of Chelsea, Vic.Philip ClancyRotary Club of Southern Mitchell, Vic.Barry McConvilleRotary Club of Picton, NSWDC GerschwitzRotary Club of Adelaide, SAJoy WeatherillRotary Club of Shoalhaven Sunrise, NSW
Silver Friends - $1,000Jack WhiteRotary Club of Liverpool, NSWKen CooperRotary Club of Raymond Terrace, NSWPeter KainRotary Club of Belconnen, ACTIan McKayRotary Club of Warrnambool Daybreak, Vic.
CEO Joy Gillett presented Bob Gardineras a Gold Companion of ARH at ourHead Office in Parramatta. Many thanksto Bob and all of our supporters.
Gold Class Company
Friends & Companions Cumulative donations from September 2014 - March 2015
ARH UPDATE
Australian Rotary Health Donation FormI wish to make a donation. My details are as follows:
Name: ………………………………………...………….... Rotarian
Address: ……………………………………………………………………....…….......
P/Code: ……… Email: .…………………………...................................................
Enclosed is my cheque for $..................................
Please credit the …………............................ Rotary Club with this donation.
Signed:……...………………..………...……….
I would also like to purchase the following merchandise:
(tick if applicable)
I authorise Australian Rotary Health, as a one-off donation,
to deduct $.............................. from my credit card account.
I authorise Australian Rotary Health to deduct a monthly/quarterly/annual
donation of $....................... from my credit card.
Visa Mastercard AMEX Diners
Card No: ……...………………..………...………………..….…. Expiry: …... / …...
CVC Number ………... Signed:……...………….……..………...….......................
TOTAL for Donation and Merchandise $
_____________
All orders includepostage and GST
Eco Bags @ $1.50 each $ __________
Colours include: Mandarin, Lilac,
Hot Pink, Apple Green, Teal
Colour/s: …...………….
Hat Day Bears @ $15 each
or set of 4 for $50
$ _____________
Bears include: Nurse, Fireman,
Graduation, Party
Bear/s .................................
Hat Day Clip-on
Bears @ $2.00 each or
20 for $35
$ _____________
Merchandise
TOTAL $ _____________
Hat Day Pins @ $2.00 each
$ _____________
$ $ $
Please fill in and return to address below: