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
Futsal
Recert, New, Small Sided
Minimum Class Size: 15
Maximum Class Size
*
DRA's Name
*
First Name
Last Name
DRA's E-mail address
*
DRA's Phone #
*
-
Area Code
Phone Number
District
*
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Venue
*
Location's Name (name of school, library, etc.)
Venue Name 2 (Specific Info about the venue
*
Calss room number, entrance number, etc)
Venue Address
*
Full Street Address (Street # and name, City, Zip)
Description
(Add here the Google URL)
Clinic Date
*
-
Month
-
Day
Year
Date Picker Icon
Clinic Start Time
*
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:
Hour
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30
Minutes
AM
PM
AM/PM Option
Clinic End Time
*
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:
Hour
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30
Minutes
AM
PM
AM/PM Option
Special Request
*
Define what this class is for (i.e. bring running shoes, bring water, you will be running, etc.)
Description
*
A COPY OF YOUR RESPONSES WILL BE SENT TO THE EMAIL ADDRESS YOU PROVIDED
Signature
Clear
Submit Form
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