SASH Registration Form
*Promoting Safe and Healthy Workplaces for California's School Employees*
This training is FREE for School District and County Office of Education employees.

Please complete this form to register for a SASH workshop.
Questions? Contact Robin Dewey at rdewey@berkeley.edu. For more information, visit www.lohp.org/sash.

Date of workshop you are registering for:
MM
/
DD
/
YYYY
Location of workshop you are registering for:
(e.g. Sacramento, Modesto)
Your answer
Registrant Information
First and Last Name:
Please enter your name as you'd like it to appear on your certificate of completion.
Your answer
Email Address:
Your answer
Job Title/Position:
Your answer
School District:
Your answer
County:
Your answer
Preferred Mailing Address:
Street line 1
Your answer
City, State, and Zip Code
Your answer
Preferred Contact Phone Number:
Your answer
Are you responsible for carrying out health and safety activities at your district?
Are you responsible for writing your district's Injury and Illness Prevention Plan (IIPP)?
Are you a member of a union? If YES, what union?
Your answer
Do you have a leadership role in your union? If yes, please elaborate.
Your answer
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