Please fill in the following information as it pertains to the
person who will attend the clinic.

Full Name.........

Home Address..

City, ST, Zip.....

Telephone 1..... : Phone 2......

Email address...

Date of Birth.... : Male Female

To what League are you affiliated? MCDL CMDL Other / None

Are you (as of today) hired to be a Coach at a pool for this summer?
If so, what Pool.... (If not, type in "None")
Pool Rep Info..

Choose a Certification Session to register as your first and second choice.

First Basic Session choice....... Clinic 1A+1B Clinic 2A+2B None and first Advanced Session choice... Clinic 1C Clinic 2C None

Second Basic Session choice... None Clinic 2A+2B second Advanced Session choice..... None Clinic 1C

Clinic #1 May 30, 31, June 1 of 2008
(1A) Fri 7-9pm Classroom, (1B) Sat 10-4pm Classroom, 4-5pm Well
(1C Advanced) Sun 12:30-5pm Classroom, 2-3pm Well

Clinic #2 June 6, 7, 8 of 2008
(2A) Fri 7-9pm Classroom, (2B) Sat 10-4pm Classroom, 4-5pm Well
(2C Advanced) Sun 12:30-5pm Classroom, 2-3pm Well

Thanks, now please tell us who is filling in this form if different than above.
Your Name....
Your Email....

Please type any questions or specific comments you may
have in the space below :