School of Health, Physical Education, and Recreation

Registration Form

Instructions: Fill out the fields and click the submit button to register online. You may also use our printer-friendly version to mail your registration form.

To register for a course offered by University of Wisconsin - Whitewater at Green Bay or Milwaukee, please use the registration link on "Course Descriptions" page for that particular course.

 

Personal Information
First Name:
Last Name:
Title:
Company:
Street Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Email:
I have an OSHA 30-hour card in: (check all that apply)
General Industry
Construction
I have an academic degree in safety and health: (check all that apply)
AS
BS
MS
I have a CHST Yes        No
I have an ASP Yes        No
I have a CSP Yes        No
Other Certifications:
I have                        years experience in construction safety.
I have                        years experience in general industry safety.
I have taken: (check all that apply)
OSHA 510
OSHA 511
What is the last letter of the alphabet in UPPER CASE?
Note: The answer to the above question is required or else the registration form will not be submitted correctly. The answer to this question is used to stop fake computer generated registrations.
Hint: The answer is a last letter in sequence "a,b,c,...." but in upper case.

 


Class Information

You can register for up to three different classes at a time using the drop-down menus below:

Class #1

Class #2

Class #3

 


Payment Information
Payment Type:

PLEASE DO NOT FORGET TO SUBMIT THIS APPLICATION WHILE MAKING ONLINE PAYMENT. REGISTRATION WILL NOT BE COMPLETE WITHOUT SUBMITTING THIS APPLICATION !

Pay online using Credit card (Opens in new browser window)
Comments: (enter coupon code here)
Amount: $
Check Number:
(Make check payable to Indiana University and mail to 400 E 7th Street, Poplars Room 629, Bloomington, IN 47405)
Purchase Order Number:
(Fax a copy of the PO at the time of registration to 812-855-7092 or attach to application form and mail to 400 E 7th Street, Poplars Room 629, Bloomington, IN 47405)