City of Antioch, Recreation Department
CONTRACTOR INSTRUCTOR PROPOSAL
Phone: (925) 776-3050 Fax: (925) 776-3079 
 (One form required for every class proposed) 
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?

YES

NO

Location

Dates

May we contact them as a reference?

YES

NO

PHONE 

Location

Dates 

May we contact them as a reference?

YES

NO

PHONE 

 EDUCATION                                        

High School

Address 

From    To 

Did you graduate? YES NO

College

Address 

From    To 

Did you graduate? YES NO

Degree: 

Other

Address 

From    To 

Did you graduate? YES NO

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?                     Yes                           No

Company

Phone 

Address 

Job Title

Responsibilities

From    To 

Reason for Leaving

May we contact your previous employer for a reference?                     Yes                           No

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.

 

What is 2 + 7?