Age Group:
Type:  
Instructor Name and Business / Organization
Instructor Name:
  
Business/Organization:
  
 
 Mailing Address:
Address
      
City   

State
Zip
 
Phone Numbers:
Home
Work
Mobile  Fax
 
 E-mail Address
  
 
  Brochure Edition (note session proposal deadlines):
 
  Course Title:
    
 
Course Description:
   
 
  Course description for Activity Guide, 25 words or less (LEAVE BLANK IF NO REVISIONS):
    
 
  Special instructions for participants - prerequisites, clothing, supplies to bring to class, etc., 25 words or less (LEAVE BLANK IF NO REVISIONS):
    
 
  Day(s) of week class held:
   
 Course Start Time:
   
 Course End Time:
  
 
 Course Start State:
    Monday, September 21, 2009 Select a Date Delete the Date 
Course End Date:
    Monday, September 21, 2009 Select a Date Delete the Date
 
 "No class" dates (include make-up class if applicable): 
No Class Dates
 
 Make-Up Class
  
 
  Total number of classes in session:
   
 
  Facility Requested (Choice 1): DCC = Danville Community Center, OHP = Oak Hill Park Community Center, VMB = Veterans Memorial Building
 
 Facility Requested (Choice 2): DCC = Danville Community Center, OHP = Oak Hill Park Community Center, VMB = Veterans Memorial Building
 
  Facility set-up instructions (be specific, e.g., include number of tables or chairs and their placement):
    
 
  Resident fee (instructor receives 60% per student - Format: ##.##):
   
 
  Additional materials fee, if applicable (must be able to justify with receipts):
   
 
  Minimum class size (# of students):
   
 Maximum class size (# of students):
 
  Minimum participant age:
   
 Maximum participant age:
  
 
  If you are a potential, new instructor, have you completed and submitted a New Instructor Application?
   
 
  Other notes for Coordinator: