MA3 Clinic Application

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Please fill out this clinic application if you are a Registered MA3 Instructor.

Email *

Organizer Name, Email and Phone Number

Approved MA3 Instructor Name *

MA3 Number *

MA3 or independent Chapter Affiliation *

Name of Clinic *

Clinic Location and Address *

Location director contact information if different from above *

Clinic Start Date *

YYYY

Number of clinic days *

Number of Students *

By submitting this form, I acknowledge I am responsible for this event, that the above information is completed to the best of my knowledge and if there are any significant changes, I will submit a new application to the MA3 Board of Directors so they may be kept informed. I agree that all MA3 Rules and Regulations will be followed during this event. I agree to have all required documents and waivers signed by every competitor and volunteer.
*

I agree

Required

A copy of your responses will be emailed to the address you provided.

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