Intercollegiate Clinic Reimbursement Program Request Form
Application is due October 1. Intercollegiate teams may apply for both clinic reimbursement and funding, but will not be approved for both.
Intercollegiate Team Name
Host USPA Club *Host Club must be current with a USPA Member Club Requirements
Contact Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
If you are combining with another IC team, please list here:
Contact for second team, if applicable
First Name
Last Name
Email
example@example.com
Expected number of participants: *All participants must be USPA Members
Clinician Name
First Name
Last Name
Clinician Email
example@example.com
Clinician Fee
Dollar amount being requested:
Proposed date of clinic
-
Month
-
Day
Year
Date
Submit
Should be Empty: