Notify the SDI of your request to host a clinic
All areas of this form MUST be completed!
Type of Clinic: Entry Level (New) Referee Clinic Referee Recertification Clinic Assistant Referee Clinic ---SELECT ONE---
Your Name:
Club or Association:
Clinic Contact Name:
Contact Phone #: Contact Email Address:
Location (city, location, address, etc):
Date of Clinic (mm/dd/yyyy):
Start Time of Clinic (HH:MM): Don't forget the "AM" or "PM"!
Approx # of Students:
Instructor (complete ONLY if you have an instructor already willing to lead this clinic, otherwise one will be assigned):
