Instructor Form

Instructor Form

Name:

Address:

City:

State:

Zip:

Cell Phone #:

Home Phone:

Email Address:


Information listed below represents a proposal I am submitting for consideration by the City of Mill Creek.

Program / Class Title:

Course Description (to be included in the Recreation Guide):

General Class Information:

First Choice:

Day(s) of week you would like to offer class:

Su M T W Th F S

Proposed Start Date:

Proposed End Date:

Class Start Time: a.m. p.m.

Class End Time: a.m. p.m.

If you would like to offer multiple class times for this course, please list each start and end time below. Example: 4 - 5 p.m. and 5:30 - 6:30 p.m.:

 

Second Choice:

Day(s) of week you would like to offer class:

Su M T W Th F S

Proposed Start Date:

Proposed End Date:

Class Start Time: a.m. p.m.

Class End Time: a.m. p.m.

If you would like to offer multiple class times for this course, please list each start and end time below. Example: 4 - 5 p.m. and 5:30 - 6:30 p.m.: 

How many weeks do you want this class to be offered (1, 2, 3, 4, 5, etc.)?

 

Please select the sessions this program would be offered:

Winter (Dec. - Feb.)

Spring (Mar. - May)

Summer (Jun. - Aug.)

Fall (Sep. - Nov.)

Age Range of Students:

Minimum number of students need to run the class:

Maximum number of students needed to run the class:

Location of class / camp (please specify any location details if needed):

Any facility requirements (e.g., tables, chairs, whiteboard):

Instructor is responsible for set-up and take-down for each class including tables and chairs, are you able to fulfill this requirement?

Yes

No

If you are not able to fulfill the set-up and take-down requirement, will you need assistance or other special accommodations? Please describe.

Instructor Payment Information:

How would you like to be paid for services rendered (please check one):

Percentage Split (70% instructor, 30% City of Mill Creek)

Volunteer Time (No payment to instructor)

Do you have CPR or First Aid Certifications?

Yes

No

If yes, please list the dates of certification:

CPR:

First Aid:

Do you have or are you able to obtain an Insurance Certificate and Endorsement that lists the City of Mill Creek as additional insured?

Yes

No

Have you taught this class before:

Yes

No

If yes, when and where?

  

Please list any experience you have teaching this class or cross training experience that enables you the ability to teach the proposed class:

 



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