EYSA: Referee Clinic Registration Form

2005 REFEREE CLINIC REGISTRATION FORM
(Space is Limited, Reservation Required*)

Name: ____________________________________________________________________________
Address: __________________________________________________________________________
City: ___________________________________	State: WA	Zip +4: ________________
Day Phone: ______________________________	Evening Phone: ________________________
FAX: ___________________________________	E-mail: _______________________________
Association:_______________________________	Club: ______________________
Date of Birth: ___________		Gender M F
Please check one:
MAY CLINIC (5/3 - 5/7 ____
MAY CLINIC (5/13 - 5/15 ____
JUNE CLINIC (6/1 - 6/10 ____

Please Choose One Clinic Date. You must attend all dates in your session. Any deviations must be arranged by the participant with the Course Instructor at the first session. Enclosed is my $45.00 check made payable to EYSA. I understand that if I chose to referee for EYSA/EKCSRA and when I pass the referee exam, I will receive a refund of the entire clinic fee. I understand it is recommended that I register with USSF for insurance purposes. Pre-registration is "strongly encouraged" - walk-ins will be charged an extra $5.00 at the door.

* Space is Limited, Reservations Are Required. Reservations are not confirmed until payment is received. If you want to do last-minute registration, go to the online registration page, find the clinic you want, and look at the box called “Available Spaces.” If there are spaces listed, then last-minute is OK. To do a last-minute registration, do the online registration an submit the form. Then just BRING your check to the class – do not mail it. Pre-registration is "strongly encouraged" - walk-ins will be charged an extra $5.00 at the door.