EmailMeForm
Request a Clinic Form
Fields marked with an asterisk are required.
Name:
*
First
Last
Club or Association:
*
e-Mail:
*
Phone:
*
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Type of Clinic:
*
Please select
Grassroots Clinic
Regional Clinic
Recertification Clinic
Fitness Test
Clinic Location:
*
i.e., Building name, room number, street address, city, ...
Estimated Number of Students:
*
Attendance Cap:
Clinic Start Date:
*
MM
/
DD
/
YYYY
Start Time:
*
HH
:
MM
AM
PM
AM/PM
End Time:
*
HH
:
MM
AM
PM
AM/PM
Clinic Continuation Date (if necessary):
MM
/
DD
/
YYYY
Start Time:
HH
:
MM
AM
PM
AM/PM
End Time:
HH
:
MM
AM
PM
AM/PM
Instructor:
Other Important Notes:
e.g., Room needs, is a lunch provided, ...