2026 PARTICIPANT REGISTRATION

Annual SCJMHS Conference

44th Annual South Central Joint Miner’s Health & Safety Conference

April 13 – 15, 2026 ~CHOCTAW CONFERENCE CENTER~ Durant, OK

2026 PARTICIPANT REGISTRATION FORM

"*" indicates required fields

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

$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 20, 2026

Total Due

Credit Card

Cancellation / Refund Policy:
-50% refund for cancellations before March 1, 2026
--NO registration refunds for NO SHOWS or cancellations after March 20, 2026
-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.

Email
This field is for validation purposes and should be left unchanged.

2026 PARTICIPANT REGISTRATION

Annual SCJMHS Conference

2026 PARTICIPANT REGISTRATION FORM

Participants Attending

Card Billing Information

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