IHSA Certified Clinic Application
This application must be accompanied with a draft of the flyer/brochure to be distributed.
Must be turned into the IHSA office no later than 30 days before the start of the clinic.
The fields in this form will accept a cursor and can be filled out prior to printing.
Level 1 Clinic Level 2 Clinic
Contact Name
Approx. # of Attendees:
Time Allotment (mins):Level 1 Required Topics
IHSA Certified Clinicians/Clinic Staff: (Must be on clinic staff for duration of the clinic)
1. Professionalism
2. Pre-Game Conference (classroom)
3. General Game Mechanics (classroom &/or on-field)
4. Conflict Resolution
5. 2-Person/3-Person (Power Point Presentation)
6. Video Clip Review
7. Conclusion, Attendance, Evaluation
1. Conflict Resolution
2. Mechanics
3. Sport Specific Level 2 Power Point
4. Video Clip Review
5. Game/Management (If Basketball - Minimum of three 3-person games worked required)
Total Time Allotment for Required Topics:
Sport
Contact Email
Date(s) of Camp/Clinic ID# Phone
Location of Clinic Clinic Cost (Assoc. Member)
Association/Organization Affiliation
Time
Targeted Experience Level Level 2Level 1
1. ID#
2. ID#
3. ID#
4. ID#
Time Allotment (mins):Level 2 Required Topics
Total Time Allotment for Required Topics:
Time Allotment (mins):Optional Topics
1. Fitness Preparation, Testing
2. Assignments
3. On Field/Court Time
4. Preventative Officiating
5. Review State Terms & Conditions
Misc. Items (please specify)
Total Time Allotment for Required Topics:
Total Time for Clinic:
Submitted by (signature):
Date
5. ID#
6. ID#
7. ID#
8. ID#
Clinic Cost (Non-Member)
