Registration and Release

NCCER Registration and Release Form
Name
Social Security Number --OR-- NCCER Number*
Address*
City*
State
Zip
Phone*
E mail
example@example.com
*By signing, I hereby authorize the NCCER Registry Department to verify information in my training records to Sponsor Representative/ Primary Administrator upon request. I release and hold harmless NCCER for this verification process.
Student Signature*
Date*

MonthDayYear
Date
Parent/Guardian Signature (Required if individual is under 18 years of age)
Date

MonthDayYear
Date
NOTE: To be entered in NCCER's Automated National Registry, you must complete and sign this Registration and Release form. This form must either be forwarded by your ATS/AAC to NCCER's Registry Department, or the ATS/AAC may choose to maintain the Registration and Release forms locally and provide the Registry Department with a blanket release form letter. This letter must include the signature of the Sponsor Representative/Primary Administrator or other authorized officer of the ATS/AAC.

Reports containing trainee/participant information, including score sheets, training prescriptions, and transcripts, should NOT be distributed without properly documented release information from the trainee/participant.
Should be Empty:

NCCER Registration and Release Form