Grassroots Safety Leadership - Registration Form

Implementing Culture Change through Grassroots Safety Leadership
The 3-Day Course
January 10-12, 2012
Embassy Suites San Diego Bay - Downtown, San Diego, CA

REGISTRATION FORM - ONLINE

To register for the 3-Day Course, please complete and submit the form below. Upon submission, you will be contacted to provide payment information.

Fields marked with (*) are required.

*Name (First, MI, Last):
Name on Badge:
Company:
Mailing Address:
City:
State:
Zip:
Plant or Site:
*Phone:
Fax:
*E-mail:
Course Package: $2,495 (cost is $2,795 if after December 10, 2011) Package includes course fees and materials, 3-days breakfast and lunch, opening reception and one dinner. Upon submission of the registration form, you will be contacted for payment information.

Please note: To make your hotel reservations, please call the Embassy Suites San Diego Bay - Downtown 1-619-239-2400. We have a block of rooms being held for our participants at $159 -$179.00/night. These rooms are being held for us until December 10, 2011 so please make your reservations accordingly. To get our lower rate, please mention that you are participating in the 3-Day Course.

Cancellation Policy: More than 2 months prior to the event-full refund. Cancellation occurring between 2 months to 1 month prior to the event-75% refund. Cancellation occurring between 1 month to 10 business days prior to the event 50% refund. Cancellation occurring less than 10 business days prior to the event-no refund. Full registration amount may be transferred to a future course if notice is given 30 days before the course begins.

REGISTRATION FORM - PRINT AND FAX

You can also register by completing and mailing or faxing our printable registration form.Please contact us at: (914) 315-6076 or info@culturechange.com with any questions.