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                                      Fox	Valley	Technical	College	
                                      Safety	Days	Registration	Form	
Register	Today	(all	information	is	required):	
	
Organization	Name:	______________________________________________	
Contact	Name	&	Title:	____________________________________________	
Address:	____________________________________________________________	
City,	State,	Zip:	_____________________________________________________	
Phone	Number:	____________________________________________________	
Email	Address:	_____________________________________________________	          	Billing:	
	
										Participant	Name:	_________________________________________	         ___	Check	Enclosed	
										Title:	________________________________________________________	     ___	Bill	my	Organization	
										Email:	_______________________________________________________	
										*DOB:	_______________________________________________________	       ___	Purchase	Order	
              	                                                                PO#	__________________	
									Participant	Name:	__________________________________________	
									Title:	_________________________________________________________	     ___	Credit	Card	
									Email:	________________________________________________________	      Call	(920)	996‐2949	with	card		
          *DOB:	________________________________________________________	      information.	Using	a	credit	card	will	
                                                                               add	2.75%	non‐refundable	 inance	
              	
                                                                               charge.		
										Participant	Name:	___________________________________________	
										Title:	__________________________________________________________	
										Email:	_________________________________________________________	
           *DOB:	_________________________________________________________	

    Review	the	next	page	to	make	your	Safety	Days	Conference	selections	

                                               Registration	Contact:		
                       Email:	sternhal@fvtc.edu	PH:	(920)	996‐2949	Fax:	(920)	735‐4771
 




                             Tuesday,	January	8	Conference	$29		
                                        class	#	63681	

9:00	AM	‐	9:45	AM	    □	A.	Work	zone	Safety	
                      □	B.	Fall	Arrest	System	


10:00	AM	‐10:45AM	    □	A.	Effective	Safety	Committees	
                      □	B.	Arc	Flash	


11:00	AM	‐	11:45	AM	 □	A.	Introduction	to	Accident	Investigation	

                      □	B.	Ergonomics	w/	Back	Injury	


11:45	AM‐	12:30	PM	 				Lunch,	time	w/	Vendors	


12:30	PM	‐	1:15	PM	   □	A.	Ripple	Effects	of	Accidents	
                      □	B.	LO/TO	

1:30	PM	‐	2:15	PM	    □	A.	Haz	Com/GHS	
                      □	B.	Con ined	Space	

2:30	PM	‐	3:15	PM	    □	A.	Record	Keeping	

                      □	B.	Scissor/Aerial	Lifts	

3:30	PM	‐	4:15	PM	    				Lessons	from	Lambeau	Field	


4:15	PM–	4:30	PM	     				Seminar	Closing

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Safety day registration form

  • 1.   Fox Valley Technical College Safety Days Registration Form Register Today (all information is required): Organization Name: ______________________________________________ Contact Name & Title: ____________________________________________ Address: ____________________________________________________________ City, State, Zip: _____________________________________________________ Phone Number: ____________________________________________________ Email Address: _____________________________________________________ Billing: Participant Name: _________________________________________ ___ Check Enclosed Title: ________________________________________________________ ___ Bill my Organization Email: _______________________________________________________ *DOB: _______________________________________________________ ___ Purchase Order PO# __________________ Participant Name: __________________________________________ Title: _________________________________________________________ ___ Credit Card Email: ________________________________________________________ Call (920) 996‐2949 with card           *DOB: ________________________________________________________ information. Using a credit card will add 2.75% non‐refundable inance charge. Participant Name: ___________________________________________ Title: __________________________________________________________ Email: _________________________________________________________            *DOB: _________________________________________________________ Review the next page to make your Safety Days Conference selections Registration Contact: Email: sternhal@fvtc.edu PH: (920) 996‐2949 Fax: (920) 735‐4771
  • 2.   Tuesday, January 8 Conference $29 class # 63681 9:00 AM ‐ 9:45 AM □ A. Work zone Safety □ B. Fall Arrest System 10:00 AM ‐10:45AM □ A. Effective Safety Committees □ B. Arc Flash 11:00 AM ‐ 11:45 AM □ A. Introduction to Accident Investigation □ B. Ergonomics w/ Back Injury 11:45 AM‐ 12:30 PM Lunch, time w/ Vendors 12:30 PM ‐ 1:15 PM □ A. Ripple Effects of Accidents □ B. LO/TO 1:30 PM ‐ 2:15 PM □ A. Haz Com/GHS □ B. Con ined Space 2:30 PM ‐ 3:15 PM □ A. Record Keeping □ B. Scissor/Aerial Lifts 3:30 PM ‐ 4:15 PM Lessons from Lambeau Field 4:15 PM– 4:30 PM Seminar Closing