2025 PARTICIPANT REGISTRATION

Annual SCJMHS Conference

43nd Annual South Central Joint Miner’s Health & Safety Conference

April 7-9, 2025 ~CHOCTAW CONFERENCE CENTER~ Durant, OK

Company Name:*
Company Address*
Street Address Address Line 2 City State ZIP Code
Person completing this form:*
First Last
Email*
Phone*
Participants Attending
IF REGISTERING MORE THAN 8 PERSONS, please fill out additional form. NOTE: We will print the name badges from the Names and Job Titles entered below.
How many Participants Attending?*
Participant #1
First Last
Job Title - Participant #1
MSHA ID NUMBER per Location - Participant #1
Participant #2
First Last
Job Title - Participant #2
MSHA ID NUMBER per Location - Participant #2
Participant #3
First Last
Job Title - Participant #3
MSHA ID NUMBER per Location - Participant #3
Participant #4
First Last
Job Title - Participant #4
MSHA ID NUMBER per Location - Participant #4
Participant #5
First Last
Job Title - Participant #5
MSHA ID NUMBER per Location - Participant #5
Participant #6
First Last
Job Title - Participant #6
MSHA ID NUMBER per Location - Participant #6
Participant #7
First Last
Job Title - Participant #7
MSHA ID NUMBER per Location - Participant #7
Participant #8
First Last
Job Title - Participant #8
MSHA ID NUMBER per Location - Participant #8
Card Billing Information
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Participants Attending Quantity
$375.00 per registrant includes all meals & refreshments served by the Conference, including attending the and any sessions or workshops. DISCLAIMER: By Registering for the conference, you understand photographs will be taken and used on our website. All Company and personal information will be protection. WE DO NOT SHARE ANY LIST OF PARTICIPANTS. Thank you for your support!!
Price:
DEADLINE TO REGISTER IS MARCH 1, 2025
Total Due
$0.00
Credit Card
Cancellation / Refund Policy:
-50% refund for cancellations before March 1, 2025
--NO registration refunds for NO SHOWS or cancellations after March 15, 2025
-There is no additional fee charged for changing names (swapping attendees) on registrations PROVIDING notice is prior to conference start date, after that a $25 processing fee be charged.
Name
This field is for validation purposes and should be left unchanged.

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2025 PARTICIPANT REGISTRATION

Annual SCJMHS Conference

Participants Attending

Card Billing Information

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