Antioch Recreation Department


Instructor Proposal

Phone: (925) 776-3050 • Fax: (925) 776-3079 – One form required for every class proposed

Submission Date
CONTRACTOR INFORMATION      
Last Name
First
M.I.
Business Name
Street Address
City
State
Zip
Phone
Cell Phone
Web Site
Email Address
COURSE  INFORMATION
Course Title
Course Description (55 Words maximum)
Course Objectives
Supply/Materials Fee
Facility (Room)
Requirements i.e. # of tables, chairs, flooring etc.  
COURSE  REQUIREMENTS
Participant Ages
Min. Class Enrollment
 
Max. Class Enrollment
 
Participant attire for class
Materials List
PROPOSED DAYS START/END TIMES # OF CLASSES PER SESSION COURSE FEE
COMPETITIVE RESEARCH
Why are you proposing this course/class? Be specific i.e. trends, need in community etc..
Who is your target market?
Are there other organizations in East County offering this course/class?  If yes, list source:
BACKGROUND INFORMATION
Have you taught this course before? YesNo
Location Dates
May we contact them as a reference? YesNo PHONE 
Location
Dates
May we contact them as a reference? YesNo PHONE 
 EDUCATION                                        
High School
Address
From

To
Did you graduate?
YesNo
College
Address
From

To
Did you graduate?
YesNo
Degree:
Other
Address
From

To
Did you graduate?
YesNo
Degree:
REFERENCES
Please list at least two professional references.
Full Name
Relationship
Company Name
Phone 
Address
Full Name
Relationship
Company Name
Phone 
Address
RELATED EMPLOYMENT  
Company
Phone 
Address
Job Title
Responsibilities
From

To
Reason for Leaving
May we contact your previous employer for a
reference?            
YesNo       
Company
Phone
Address
Job Title
Responsibilities
From

To
Reason for Leaving
May we contact your previous employer for a reference?
YesNo  
ADDITIONAL INFORMATION
Upon Approval of this proposal, instructors will be required to complete fingerprinting and a TB test (required for teaching participants under age 18), provide insurance and worker’s compensation and complete a W-9.  Submitting a proposal does not guarantee that the class or activity proposed will be added to the City of Antioch’s recreation offerings. Additionally, once added no guarantees are made that the City of Antioch will automatically continue offering the activity or program.