Fall Protection : Registration - Clockwork Safety Equipment Training

- AT YOUR WORKPLACE -

Please read and fill out this form before the program starts, if you have any questions or concerns talk to the instructor immediately

GENERAL GUIDELINES, POLICIES AND CONDITIONS

Everyone taking part in the course must participate in all activities during the day in order to receive a passing mark.
Everyone taking part in this course must treat everyone with respect (no bulling, harassing or disrespecting).
Everyone taking part in this course must be physically and mentally able to conduct all activities involved.
Immediately upon successful completion, Clockwork Safety & Equipment Training and its instructors are free from all liability in regards to personal injury, property damage or any other claims regardless if the trainer is still present.
The personal information you provide will remain confidential but will be accessed for recertification and promotional purposes.
You will read all legal documentation regarding the course and our company and will ask for clarification if anything is unclear.
You will not be under the influence of any alcohol or drugs during this program. Prescription medication must be disclosed.

Name (as wanted):*

Company :*

Phone :*

Email :*

1 - Have you ever worked at heights before ? (Trained or not)

No
Yes

How many Days / Months / Years ?

2 - Have you ever been trained in fall protection before ?

No
Yes

3 - Have you ever had a valid drivers license ?

No
Yes

4 - Have you ever been involved in a fall accident ?

No
Yes

Brief description of what the incident was

5 - Is there any reason you'd have trouble with an English written test ?

No
Yes

what would be the reason ?

6 - Will you require any kind of assistance with the test ?

No
Yes

What type of Assistance ?

How did you hear about us ?

By signing this document you are confirming that the above information to be true and that you have read and understood all CS&ET's policies, terms and conditions.

Date*

Signature*

This program was created with the intent of giving you a better understanding of this equipment and how to use it properly. Although every effort is made to keep the content as current and updated as possible, this manual and course should not constitute as legal advice or a formal order of recommendations.