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Youth Enrichment Course Proposal 15180 Canada Ave Rosemount, MN 55068 651.423.7920 Please complete all items on this form and return it to the address listed above. Use a separate form for each class you propose to teach. Please note: This proposal is not a confirmation of your current class. All scheduled classes are at the discretion of the class scheduler. A submitted proposal is NOT an approved class. Confirmations/Contracts of selected classes will be emailed 1‐2 weeks prior to brochure printing. Instructor Info Instructor/Contact Name ______________________________________________________________________________________ Mailing Address ______________________________________________________________________________________________ Organization Name _____________________________________________________ Social Security # ______________________ Phone: Home ______________________ Work _____________________________ Mobile _____________________________ Fax: Home ______________________ Work _____________________________ E‐mail Address _______________________________________________________________________________________________ One Sentence Biography In 35 words or less please write a biography of yourself that highlights the experience you bring to the proposed class. * Please include a jpeg photo of yourself to help us promote your class. Class Details Course Title __________________________________________________________________________________________________ Course Description In 50 words or less please write the description as you would like to see it printed in our catalog. Be specific and be sure to include at least 3 benefits for students taking the course. Number of Class Meetings Time Preferred Class Size
Minimum/Maximum Day/Evening of the Week Building Preferred Special Room Request Target Audience/Age Parent/Child Pair Family Child* *If this class is for children, what age/grade group? _________________________________________________________________ What benefit(s) will students receive from this class (skills learned, projects completed, etc)? ____________________________________________________________________________________________________________ What is the class format (lecture, workshop, demonstration, etc)? ____________________________________________________________________________________________________________ Please describe the main topic areas below: Meeting Major Topic Areas 1 2 3 4 5 6 7 8 9 10 Supplies What should the students bring to class (if anything)? Are there materials which should be included in the class fee? Yes No If Yes, what are they and how much do they cost/student? __________________________________________________________ Yes No Are students to purchase all or additional class supplies on their own? If Yes, what are they and how much do they cost/student? __________________________________________________________ # of Photocopies Needed we will do them for you, but need the originals one week prior to the first class date ________________________________ Audio/Visual Equipment Needed: _______________________________________________________________________________ (We do not have LCD & slide projectors available) Are you interested in offering this or another class to Youth or Adults with Disabilities? Yes No Prep Time Do you have set‐up time that requires you either to arrive early at the class site or complete a specific task beyond normal Yes No preparation (food shopping, etc)? If Yes, please describe the nature and amount of prep time requested Instructor Recommendations Select One: Volunteer Fee for Service Requested Instructor Rate of Pay $ _____________________________ Personnel Application 15180 Canada Ave Rosemount, MN 55068 651.423.7920 Independent School District 196 is an equal opportunity employer. Selection of applicants will be made without reference to race, creed, color, sex, age, or national origin, disability, economic or marital status. Personal Information Full Name ___________________________________________________________________________________________________ Permanent Address ___________________________________________________________________________________________ Present Address (if different) ___________________________________________________________________________________ Organization Name _____________________________________________________ Social Security # ______________________ Phone: Home ______________________ Work _____________________________ Mobile _____________________________ Fax: Home ______________________ Work _____________________________ E‐mail Address _______________________________________________________________________________________________ Yes No Are you legally eligible for employment in the United States? If, during the past five years, you have been convicted of a crime for which a jail or prison sentence was or could have been imposed, check this box and attach a separate sheet of details. If there are any criminal charges or proceedings pending against you, check this box and attach a separate sheet with details. If you have been convicted of any offense involving the sexual molestation, physical or sexual abuse, or rape of a child, check this box and attach a separate sheet with details. Can you perform all the essential functions of the position which you are applying for? Yes No Yes No If not, could you perform all the essential functions with reasonable accommodations? If yes, how? __________________________________________________________________________________________________ Have you ever been discharged for misconduct, unsatisfactory service, or forced to resign from any position? Yes Personal Information High School Undergraduate Graduate Summer School Other Name & Place Course or Major/Minor Diploma/Degree Years No Work Experience Dates To & From Name & Location of Employer Position Held Salary Reason for leaving present or last position _________________________________________________________________________ References Name Address Phone Number Date __________________________ Signature _________________________________________________________ If you secure another position or no longer wish this application to be considered, please notify Human Resources at 651.423.7632. Application consideration will be discontinued six months from date of application.