2019/2020- Indiana SRC Clinic Setup Form
DRA please complete your clinic setup form below. You will receive a confirmation email back when the clinic has been approved.
Clinic Type
*
Recert
New Entry Level
Small Sided
Assignors
Recert, New, Small
Minimum Class Size: 15
Maximum Class Size
*
DRA Contact Info
*
Name, Email & Cell Phone
E-mail address
*
District
*
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Venue
*
Name of Place, Specific Room(if applicable) Street, City, Zip
Link for Venue directions
*
i.e. Google Maps or MapQuest URL
Clinic Date
*
-
Month
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Day
Year
Date Picker Icon
Clinic Start Time
*
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:
Hour
00
30
Minutes
AM
PM
AM/PM Option
Clinic End Time
*
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:
Hour
00
30
Minutes
AM
PM
AM/PM Option
Special Instructions
*
Description
(Only for certain age? etc)
A COPY OF YOUR RESPONSES WILL BE SENT TO THE EMAIL ADDRESS YOU PROVIDED
Submit Form
Should be Empty: