Workplace Safety
~
&
Prevention
Services
'"
D D
D D
D D
D D
D D
BOOKING FORM
Health & Safety Awareness Presentation
At the School:
Assembly
Language of Instruction English
French
Please provide the following information for each session.
Date of Session Start Time / Finish Time # of Students Expected Teacher on duty
1. ________________ __________________ __________________ ______________
2. ________________ __________________ __________________ ______________
3. ________________ __________________ __________________ ______________
4. ________________ __________________ __________________ ______________
Special Notes (special interest, challenges, co-op, grade)
AV Requirements Overhead: Yes No
TV/VCR: Yes No
Multimedia Projector: Yes No
Facilitator Information 1
Facilitator Information 2
Name:
Company:
Tel: Fax:
Name:
Company:
Tel: Fax:
Session Verification – to be completed by Teacher/Facilitator
Final # of students per session
1. _______ Teacher’s Initial - ____________
2. _______ Teacher’s Initial - ____________
3. _______ Teacher’s Initial - ____________
4. _______ Teacher’s Initial - ____________
This section has to be
completed by either the
Teacher or Facilitator
Teachers are required to remain in the classroom during the presentation.
Facilitators Expenses
Mileage ________________
Meals ________________
Please note that an incomplete form will not be processed
for expenses. Submit this completed form with your
expense claim form and all receipts. Receipts must be
original and submitted within 30 days of function.
COMPLETE AND FORWARD THIS FORM TO THE ADMINISTRATOR:
Email Address: hsapregistrations@wsps.ca Fax #: 905-614-1414
October 2013
