2012 NASF Clinic Enrollment Form

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2012 NASF Clinic Enrollment Form

Fields indicated with a *are mandatory.

* Contact Name:		* Email:
* Day Phone:		Evening Phone:
* Address:		* City:
* State:		* Zip:
* Clinic Location:		*Indicate Sport:
* Indicate Age Group:		*Other Sport


Please use one Form to sign up Multiple Clinics.

Session 1 Date		# of Participants:		Times	# of Days: See Rates Below	$	=	Total Cost:	$

Session 2 Date		# of Participants:		Times	# of Days: See Rates Below	$	=	Total Cost:	$

Session 3 Date		# of Participants:		Times	# of Days: See Rates Below	$	=	Total Cost:	$

Session 4 Date		# of Participants:		Times	# of Days: See Rates Below	$	=	Total Cost:	$

TOTAL PREMIUM: (Must be paid by Check or Money Order):							$
RATES: Classroom only - $0.60 per participant per day Instructional/Playing - $1.10 per participant per day. $125.00 minimum premium for each clinic

* Are you obligated to name any organization as an Additional Insured. If so, please complete:
Additional Insured Name Complete Address Relationship to You

Make Check payable to:	For Credit Card Information:
Special Markets Insurance Consultants 2615 Post Road Stevens Point, WI 54481 Email: NASF@specialmarkets.com	Special Markets Insurance Consultants 2615 Post Road Stevens Point, WI 54481 Phone: 800-727-7642 ext 311 Fax: 715-344-6126