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> Little League Online > District Officers > Remote Clinic Form

Remote Clinic Form

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Host Name

District

Host Address

Host Address Line 2

Host City

Host State

Host Phone Number

Enter a valid phone number. Example: 123-456-7890

Host Email Address

Enter a valid email address. Example: name@company.com

Host Website

Clinic Location

Clinic Address

Clinic Address Line 2

Clinic City

Clinic State

Clinic Zip Code

Host Zip Code

Clinic Phone Number

Enter a valid phone number. Example: 123-456-7890

Directions to the clinic

Dates of Clinic

Clinic Times

Lunch Provided

Yes

Clinic Fee

Checks should be made payable to

Region in which Clinic will be Offered

Notes

Lodging

Lodging Address

Lodging Address 2

Lodging City

Lodging State

Lodging Zip Code

Lodging Phone Number

Enter a valid phone number. Example: 123-456-7890

Lodging Rates

Would you like to host an Umpire Clinic in conjunction with the Road Show Clinic

Yes

Would you like to have a separate two hour presentation on Tournaments on Friday evening specifically for the DA's and ADAs?

Yes

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Remote Clinic Form