Host Your Own Clinic – Application

Your Name:*
Host Church / Business / Association:*
Address where clinic is hosted:*
Your Phone:*
Your E-mail:*
Contact me about Hosting a Clinic:*
I have read the room set up instructions and can comply with the room arrangements as requested:*
I have access to the following projection equipment in the clinic room: (check all that apply)*
I can provide coffee and water throughout the clinic:*
I understand that QuickStep Coaching has the right to cancel any clinic that does not reach the required 6 registered clinicians one week prior to clinic date:*
How did you hear about Hosting Your Own Clinic?: (check all that apply)*
Word Verification: