Lunch & Learn – Actionsinc.org

Partnering to Protect- Lunch & Learn

Name *

First

Middle

Last

Title/ Rank

PID #

Date of Birth *

Agency Name *

Agency Mailing Address *

Address Line 1

Address Line 2

City

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Zip Code

Phone Number (work) *

Work Extension *

Put N/A if none.

Phone Number (Cell) *

Email *

Registration Requirements

Registration: Course registration must be made 48 hours prior to the scheduled course date.

Cancellation: Notify ACTIONS, Inc. of Brazoria County as soon as possible in the event you are no longer willing or able to attend any course you are registered for

Wavier of Liability/Certification of Insurance Protection

I hereby release, absolve, and forever hold harmless ACTIONS, Inc. of Brazoria County, agents, officials, and employees from any and all liability for death, injury, or accident occurring or inflicted upon me while attending or participating in any training exercise or instruction conducted on their behalf.

I certify that I am covered by insurance or other protection for any death, injury, or accident occurring or inflicted upon me while attending or participating in any training exercise or instruction conducted on behalf of ACTIONS, Inc. of Brazoria County.

Check one below *

I have read and agree to BOTH the Registration Requirements and Wavier of Liability/Certification of Insurance Protection.
I do not agree.

Once submitted, you will be registered for your selected course. You will be notified ONLY if the course is CANCELLED, becomes FULL, or you are placed on a WAITING LIST.

Signature *

Clear Signature

Date & Time *

Date

Time

Partnering to Protect- Lunch & Learn

*Once submitted, you will be registered for your selected course. You will be notified ONLY if the course is CANCELLED, becomes FULL, or you are placed on a WAITING LIST.*

Once submitted, you will be registered for your selected course. You will be notified ONLY if the course is CANCELLED, becomes FULL, or you are placed on a WAITING LIST.