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 (1)

44th Annual South Central Joint Miner’s Health and Safety Conference April 13 – 15, 2026 ~ CHOCTAW CONFERENCE CENTER ~ Durant, OK

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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

Phone - Participant #1

Job Title - Participant #1

MSHA ID NUMBER per Location - Participant #1

Participant #2

First Last

Phone - Participant #2

Job Title - Participant #2

MSHA ID NUMBER per Location - Participant #2

Participant #3

First Last

Phone - Participant #3

Job Title - Participant #3

MSHA ID NUMBER per Location - Participant #3

Participant #4

Phone - Participant #4

Job Title - Participant #4

MSHA ID NUMBER per Location - Participant #4

Participant #4

First Last

Participant #5

First Last

Phone - Participant #5

Job Title - Participant #5

MSHA ID NUMBER per Location - Participant #5

Participant #6

First Last

Phone - Participant #6

Job Title - Participant #6

MSHA ID NUMBER per Location - Participant #6

Participant #7

First Last

Phone - Participant #7

Job Title - Participant #7

MSHA ID NUMBER per Location - Participant #7

Participant #8

First Last

Phone - Participant #8

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 and sessions served by the Conference.

Price:

DEADLINE TO REGISTER IS MARCH 20, 2026

Total Due

Credit Card*

Payments can be made by credit card on our website www.scjmhsc.org

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 IF notice is prior to the conference start date. After that, a $25 processing fee will be charged.

By registering for the conference, you understand that photographs will be taken and used on our website.

ALL PERSONAL INFORMATION WILL BE PROTECTED
THANK YOU FOR YOUR SUPPORT!!!!

2026 PARTICIPANT REGISTRATION

Annual SCJMHS Conference

2026 PARTICIPANT REGISTRATION FORM (1)

Participants Attending

Participant #2

Participant #3

Participant #4

Participant #5

Participant #6

Participant #7

Participant #8

Card Billing Information

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