size="25"> 2nd Contact: 2nd Contact Phone: Ext. Estimated Enrollment: Football Record: Other Sports Records: Example: Basketball, 12-0 Baseball 15-0, Track, 3 First Place 2 Second Place

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