Special Interest Class Proposal Form

1

Name: 

 *

Name:

2

Business/Organization (if applicable):

Business/Organization (if applicable):

3

Address:

 *

Address:

4

Contact Phone Number: 

 *

Contact Phone Number: ext.

5

Website (if applicable):

Website (if applicable):

6

Email Address: 

 *

Email Address:

7

Area of Interest (you may choose more than one):

 *

Area of Interest (you may choose more than one):

Arts & Hobbies	Dance, Tumbling, Cheer & Music	Equestrian
Fitness	Preschool	Sports
Martial Arts	Specialty Program	Other If other, type text here.

8

Age group(s) you are interested in teaching (you may choose more than one):

 *

Age group(s) you are interested in teaching (you may choose more than one):

Preschool

Youth

Teen

Adult

Senior Adult (50 years +)

9

Brief Course Name/Description: (if applicable):

 *

Brief Course Name/Description: (if applicable):

10

Please describe your skills, experience, certifications, degrees, etc. that qualify you to teach this type of class (attached resumes are welcome in addition to this description; please include copies of any certifications):

 *

Please describe your skills, experience, certifications, degrees, etc. that qualify you to teach this type of class (attached resumes are welcome in addition to this description; please include copies of any certifications):

11

Have you ever been convicted of a crime in any domestic, foreign or military court, regardless of whether the convictions was later set aside of expunged?

 *

Have you ever been convicted of a crime in any domestic, foreign or military court, regardless of whether the convictions was later set aside of expunged?

Yes

No

12

Do you presently have any criminal charges pending in any court?

 *

Do you presently have any criminal charges pending in any court?

Yes

No

13

If you have answered "yes" to either or both of these questions, please give the details of offense(s), for which convicted (or trail pending), date(s) of conviction(s), jurisdiction(s), (court, county & state), and disposition(s) had been set aside or expunged, please give date(s). 

If answered "no" to either or both of these questions, please write N/A.

 *

If you have answered "yes" to either or both of these questions, please give the details of offense(s), for which convicted (or trail pending), date(s) of conviction(s), jurisdiction(s), (court, county & state), and disposition(s) had been set aside or expunged, please give date(s). If answered "no" to either or both of these questions, please write N/A.

14

Upload a file: (resume, certifications etc)

Upload a file: (resume, certifications etc) Click button for uploading file Clear Maximum size allowed: 5 MB Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

15

By selecting "I Agree", I am submitting truthful information to the best of my ability and I understand that this is a request to teach a special interest class in contract with the Town of Queen Creek.

 *

I agree

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