OSHA 10 Registration Form

Student Name

First NameMiddle NameLast Name

Name of Employer

Birth Date

MonthDayYear

Race/Ethnicity

Gender

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Highest Degree Earned

Student E-mail

example@example.com

Mobile Number

Format: (000) 000-0000.

Phone Number

Format: (000) 000-0000.

Work Number

Format: (000) 000-0000.

Waiver

Southeastern Illinois College&#13;&#10;OSHA  10&#13;&#10;Medical Release/Waiver Form&#13;&#10;Being the student or  parent or legal guardian of the person on the registration,&#13;&#10;I hereby give my permission for the student named above to participate in the event known as OSHA 10 and hereby voluntarily RELEASE AND FOREVER DISCHARGE AND HOLD HARMLESS Southeastern Illinois College, its instructors, volunteers and/or sponsors of the event against any and all claims, demands, damages, expenses, causes of action or liability of any kind whatsoever, that said child, his/her next of kin, heirs, guardians, representatives or assigns, may have for personal injury, bodily injury, or property damage arising from participation in and/or observation of activities of the event. It is my intent that no claim of any person or entity through my child, me or my guests, or any claims of any person or entity against me or my guests shall ever cause Southeastern Illinois College, its instructors, volunteers and/or sponsors of the event to incur any expense of any kind whatsoever.&#13;&#10;Photograph/Media Release: All college activities may be recorded & video recorded for college purposes. Entry into campus grounds & buildings constitutes consent to be photographed or videotaped for college purposes.&#13;&#10;&#13;&#10;

Signature

SIC OSHA 10