2018-2019 - Indiana SRC Clinic Setup Form
DRA please complete your clinic setup form below. You will receive a confirmation email back when the clinic has been approved.
E-mail address
*
Clinic Start Time
*
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Hour
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30
Minutes
AM
PM
AM/PM Option
Clinic End Time
*
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Hour
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30
Minutes
AM
PM
AM/PM Option
Clinic Date
*
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Month
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Day
Year
Date Picker Icon
District
*
DRA Contact Info (Name, email, & cell phone)
*
Clinic Type
*
Recertification Clinic
Entry Level Clinic
Venue - Name and Address
*
Link for directions to venue - i.e. Google Maps or Mapquest URL
*
Minimum Class Size
*
Maximum Class Size
*
Special Instructions
*
A COPY OF YOUR RESPONSES WILL BE SENT TO THE EMAIL ADDRESS YOU PROVIDED
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