Membership Registration

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Primary Contact Information

CEO (or most Senior Excecutive in Canada)

Operational Leader (e.g.: General Manager, Director, CIO, COO, Manager):

Company Information:

Assistant Contact Information:

Requested Information


1. As a member of the CEO Health + Safety Leadership Network, I agree to the following terms of participation:

At least 1 must be checked

2. Please list the top three goals of your organization with a brief (1-2 sentence max.)

At least 1 must be provided

3. Please list the top three strengths that you believe your organization has to offer Members of the CEO Health + Safety Leadership Network

At least 1 must be provided

4. Please identify one immediate need that you would like to focus on:

5. Please identify one long-term challenge that you would like to resolve:

6. There are many ways to demonstrate your commitment to creating a culture of health and safety in your workplace (i.e. commitment statement on the website, publicly available report on health and safety performance, support of health and safety initiatives and events). Please indicate how you are currently demonstrating this, or are willing to as a result of your participation in the Network. (Please see Membership Criteria – The Journey to Safety Excellence – for examples).

At least 1 must be provided

7. How do/will you promote your organization’s health and safety culture within your own professional network?

At least 1 must be provided

8. Please provide a brief CEO commitment statement.

9. We are looking for CEOs only to participate on our Steering Committee. Are you interested in learning more about this opportunity?

Please select an option

By submitting this form, you agree to the terms of participation outlined above, and give consent to share your company name and logo, as well as the CEO commitment statement in promotional and advertising materials and on the CEO Health + Safety CEO Leadership Network website. Please see our privacy statement here. CEO Health + Safety Leadership Network reserves the right to photograph its events, and from time to time we use these photos in our publications. By registering for any of our events, you understand and acknowledge that your photograph may be taken and used, per CEO Health + Safety Leadership Network discretion.

Thank you for taking the time to complete this form. A confirmation will be sent to you when your membership is approved and activated. In the meantime, if you have any questions, please do not hesitate to contact us at