Program Proposal Form

Program Information:*

Submission Date:

Preferred Season (Choose the most appropriate option):

Age Group(s): (Please check all that apply)

Gender:

Which of the following best describes the program you are proposing?

Suggested Group Size: (i.e., Minimum 5 people – Maximum 15 people)

Suggested day(s) of the week you are available to instruct: (Please check all that apply):

Suggested Time: (Please check all that apply):

Program Description:

Suggested Program Length:

Suggested Rate of Pay:

Employment Relationship:

Supply Costs:(Detailed invoice for supplies will be required at time of billing)

Equipment Required: (mats, tables, chairs, etc.)

Facility/Room Needs: (size, flooring, mirrors, etc.)

Name*

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Enter Email Confirm Email

Website

Qualifications/Experience: PLEASE ATTACH RESUME. 3mb

Max. file size: 3 MB.

References: (Work, Personal, Educational)

A. Name:

A. Relationship:

A. Phone:

B. Name:

B. Relationship:

B. Phone: