Instructor Name:
    
  Business/Organization Name:
   
 
 Address
    
City    State   Zip
   
 
Phone:
Home
 
Work
 
Mobile
 
Fax
 
 
E-mail Address                          Birth Date (MM/DD/YYYY)
   

Gender:
 
Please describe your background and experience:
    
 
Proposed course and/or subject matter:
    
 
Proposed age range for class participants:
   
 
List 3 program outcomes (i.e., As a result of this class, participants will be able to...):
    
 
  Why should the Town of Danville offer your class?:
    
 
  List other locations/agencies where you have taught or are already teaching the proposed class:
    
 
  Provide 3 references with phone numbers:
    
 
  Have you submitted a Course Proposal in addition to this application?
  
 
  A Program Coordinator will contact you to arrange an interview after receiving your Application and Course Proposal. Please be prepared to provide a course outline, sample materials, information about your organization, etc.