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Clinic Information
Preferred Clinic Dates (Make Two Choices)	First Choice (Date):		First Choice Day(s) of the Week:
	Second Choice (Date):		Second Choice Day(s) of the Week:
Nearest Airport	Airport Name:		Miles to Clinic:
Nearest Lodging	Hotel Name:		Miles to Clinic:

Please Choose the Type of Clinic You Would Like to Host Below * (You Can Make More Than One Selection)
Yes No One Day Clinic	Yes No Two Day Clinic	Yes No Be An 11 Seminar	Yes No In-Service Certification	Yes No Regional Certification
Please Answer the Following Questions to Better Assist You
Are You BFS Certified? Yes No
Have You Ever Hosted or Attended a BFS Clinic? Yes No
Have You Ever Hosted or Attended a BFS Be An 11 Seminar? Yes No
Please Enter Below Any Comments/Questions You Might Have About BFS Clinics