Host Your Own Clinic – Application

Host Your Own Clinic – Application

Your Name:*
Your Phone:*
-
Your E-mail:*
Host Group / Business / Church / Association:
If Classroom Clinic, address where clinic will be hosted:*
Contact me about Hosting a Clinic:*
If Classroom Clinic, I have read the room set up instructions and can comply with the room arrangements as requested:
If Classroom Clinic, I have access to the following projection equipment in the clinic room: (check all that apply)
If Classroom Clinic, 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: