Clinician Form Clinician Form Clinician Name* First Last Clinician Email* Clinic Type*R2Score KeeperAdult Onsite Supervisor* Adult Onsite Supervisor – each clinic must have an adult (USAV eligible) that is an onsite supervisor. This person is responsible for the clinic sign-in sheet. Their signature is required on this sheet before submission. Adult Onsite Supervisor Phone #* Clinic Date* MM slash DD slash YYYY Clinic Time* : Hours Minutes AM PM AM/PM Clinic Location* Clinic Sign In Sheet (File)*Max. file size: 256 MB.Scanned copied only, no pictures please.Club Contact Name* First Last Club Contact Email* Number of Clinic Participants*R2 must match the number on the Clinic Sign In Sheet. Scorekeeper must match the Clinic Sign In Sheet and Purple Score Sheet. Clinician will be paid based off of this number.