Host Your Own Clinic Form

Refer to the Host Your Own Clinic Information Sheet for instructions on setting up your clinic and a list of clinicians.  Once your clinic details are confirmed (note-you do not need to confirm a clinician before submitting this form - Marilyn can work with you on confirming a clinician), use this form to send your Club-sponsored Clinic information to Marilyn for approval. Contact Marilyn with any questions.

Please enter your Club Name
Please enter your Club Director's Name
Please enter your Club Directors Email Address
Please enter your Club Directors Phone Number
Please enter the date you want to hold your clinic
Please enter the start time for your clinic.
Please enter the Site name and full address for your clinic
Please enter the Clinic Contact (if different than Club Director)
Please enter the Clinic Contact email address (if different than Club Director)
Please enter the Clinic Contact phone number (if different than Club Director)
Please enter the name of the clinician that you have arranged or would like to give your clinic
Answer Yes if you will allow attendees from outside your club
Please enter dollar amount if you will have a charge for outside attendees (put $0 if none)
Click here to submit your request(*) denotes a required field.