SAMPLE FORM - USE OF LAB/STUDIO EQUIPMENT

CENTER FOR BEADWORK & JEWELRY ARTS

On this date:   _____________________

Dear Student,

In consideration of your payment to us of $ ____________ , we agree to provide you with the following course names: ____________________________ at our studio at 718 Thompson Lane, Ste 123, Nashville, TN  37204.

We want to make sure you understand that jewelry construction involves the use of some potentially hazardous materials and dangerous tools.   Therefore, we want to receive your written acknowledgment that potentially hazardous materials and dangerous tools you will use in this class have been identified for you, that you have been taught and understand how to safely use these materials, as well as all the tools and machines in the studio.   YOU AGREE TO ASSUME ALL RISKS CONNECTED WITH YOUR USE OF THE TOOLS, MACHINES, CHEMICALS, AND OTHER MATERIALS IN THIS STUDIO AT ALL TIMES.

If you agree to all the foregoing, please sign in the space provided below:

Sincerely,                                ACCEPTED AND AGREED:

_______________                 ___________________________
for CBJA                                Student

Workplace Chemical List
EDTA ULTRASONIC SOLUTION  (at sink)
ACETYLENE (at vented solder table)
ETHANOLOAMINE ULTRASONIC SOLUTION (at sink)
XANTHENE-O-BENZOATE HARD FLUX (at vented solder table)
BORATES, TETRA, SODIUM SALTS HARD FLUX (at vented solder table)
SODIUM BISULFATE PICKLE (at vented solder table)
AMMONIUM PHOSPHATE, DIBASIC HARD FLUX (at vented solder table)
SULFURATED POTASH LIVER OF SULPHUR (at sink)

Tools
HIGH SPEED DRILL
GRINDING WHEEL
POLISHING WHEEL
TORCH AND TORCH HEAD
SOLDERING TILE
FILES, HAMMERS, BURNISHING TOOLS, STAMPS, SAWS