2026 Fall - Staff Clinic

Registration Form - Fall 2026 Staff Clinic

All registration forms and fees are to be completed and paid via this form no later than July 24th, 2026. No information or forms will be accepted after this date.
Personal Information
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Age
Date of Birth

MonthDayYear
Date

Spouse and Emergency Contact Information

Please provide emergency contact information.
Relationship Status
Spouse Name

First NameLast Name
Spouse Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Clinic Registration Fee

Fee includes $400 CIAA Registration Fee and $50 FOA Dues ($25 Recognition and $25 Regular Dues).

$450.00

Clinic Social Guest

Social is on Friday night.

$25.00

Enter coupon

Subtotal

Tax

Total

Registration Form - Fall 2026 Staff Clinic