Downingtown Area Recreation Consortium

PROPOSAL FORM FOR INSTRUCTION

(please print)

Instructor Name:________________________________________________________

Address:_______________________________________________________________

City: ______________________________   State :_______ Zip:____________________

Home Phone:______________________ Work Phone:_________________________

Cell Phone:________________________ email:_______________________________

Social Security#:_____________________ Driver’s License#:___________________

 

Proposed Day of Program (please circle):   Mon.   Tues.   Wed.   Thurs.   Fri.   Sat.    Sun.

Proposed Time of Program (i.e. 7:00 to 9:00PM): ________________________________

Proposed Start Date of Program:__________________________________________

Proposed Length of Program (i.e. # of classes):_________________________________

Proposed Topic of Instruction/Program Title:

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Proposed Location of Program (Refer to Instructor Fact Sheet):

1^st choice____________________________ 2^nd choice________________________

  Proposed Course Description for Brochure Copy: (attach additional sheet if necessary)

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PLEASE NOTE: If you are teaching/coaching a course dealing with children you must forward a copy of your Criminal Background Check & Child Abuse History Clearance forms to the DARC Office before classes can begin. If you need to obtain these forms they are available at the DARC Office, 114 Bell Tavern Road , Downingtown , PA 19335 . There is a $10 fee per form to have them processed.

 

Additional Information (Material needed by participant, level of experience, etc.):

______________________________________________________________________

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Instructor’s Prior Experience/Knowledge of Topic: (attach sheet if needed)

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References:

Name                                      Association with Instructor                   Phone Number

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