Grassroots Safety Leadership - Registration Form

Implementing Culture Change through Grassroots Safety Leadership
The 3-Day Course
October 26-28, 2010
Philadelphia Downtwon Courtyard, Philadelphia, PA

This course will be led by Harvey J. Liss, Ph.D.

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: $2,295 (cost is $2,595 if after October 1, 2010) 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 Philadelphia Downtown Courtyard by Marriott 1-800-887-8130. We have a block of rooms being held for our participants at $149.00/night. These rooms are being held for us until October 4, 2010 so please make your reservations accordingly. To get our lower rate, please mention that you are participating in the Implementing Culture Change 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.