What kind of clinic would you like to request?
(check as many as needed and select at least 2 dates)

Clinic Type	Number of Students Expected	Date - 1st Choice (mm/dd/yy)	Date - 2nd Choice (mm/dd/yy)	Date - 3rd Choice (mm/dd/yy)	Date - 4th Choice (mm/dd/yy)
Entry Level (Grade 8) Part A
Entry Level (Grade 8) Part B
Grade 9 Referee
Bridge (Grade 9 to Grade 8 Upgrade)
Recertification

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What time would you like to start the clinics?

Start time:

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Proposed location for the clinic?

Proposed location:

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Which MYSA club are you with?

MYSA Club:

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Tell us how to get in touch with you:

Name
E-mail
Tel
Cell

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Enter any additional requests/comments in the space provided below:

I have read and understand what the club obligations are.