Intercollegiate Clinic Reimbursement Program Request Form

Intercollegiate Clinic Reimbursement Program Request Form
Intercollegiate Team Name
Host USPA Club *Host Club must be current with USPA Member Club Requirements
Contact Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
If you are combining with another IC team, please list here:
Contact for second team, if applicable

First NameLast Name
Email
example@example.com
Expected number of participants: *All participants must be USPA Members
Clinician Name

First NameLast Name
Clinician Email
example@example.com
Clinician Fee
Dollar amount being requested:
Proposed date of clinic

MonthDayYear
Date
Should be Empty: