LIFELONG LEARNING
Class Proposal Form

Return to: 
Peoria Community Services Department
Attention: Lifelong Learning Class  Program
Rio Vista Recreation Center
8866 W. Thunderbird, Peoria, AZ 85381
                        Fax: 623-773-8628
e-mail: andrea.traganza@peoriaaz.gov


*Please include a course outline (bulleted format acceptable) 
showing what you would cover in your proposed class meetings. 

Name:
Today’s date:
Daytime Phone:
Alternate Phone:

Email:
Mailing Address:

City/State:

Zip Code:
Proposed Class
Title:

Age Group:   (check as many as apply)           [] Grade K-2       [] Grade 3-8    [] Grade 9-12   [] Adults               

What is your experience teaching this topic? (How long have you taught? Where have your taught?)










Who may we contact to verify your experience and skill teaching this subject matter? (Supervisors, Coaches, Parent of minor student, 
Adult student, co-worker, etc.) 

1.	Name:_____________________________________________________Phone_(______)_______________________
Relationship to you:___________________________________________________________________________________ 

2.	Name:_____________________________________________________Phone_(______)_______________________
Relationship to you:___________________________________________________________________________________ 

3.	Name:_____________________________________________________Phone_(______)_______________________
Relationship to you:___________________________________________________________________________________


Please list any certifications, professional affiliations, memberships, or  formal training you have related to this topic:






Equipment/Special room set-up needs:







Class Description:  (4-6 Sentences describing main learning outcomes of this class)












Total number of class meetings:

Length of each class session:  (circle one)
1 hour        1.5 hours        2 hrs        Other: ___________
Availability
to teach:


   [] Winter       []   Spring        []  Summer            []  Fall

Please indicate below the time frames during which you are available to work…
Time Frames
Mon
Tue
Wed
Thu
Fri
Sat

Comments

AM



PM



What is your compensation request? 

$____ per hour of instruction        or                $_____ per student (must be a business owner/sole proprietor;   
           (part-time city employee)                                      liability insurance may also be required.)


Estimated supply costs per student:$_______________ (if applicable)
Supplies needed:



*Class proposals are accepted on an on-going basis.  Applicants may be considered to teach a new class proposed 
& created by you, or to teach an advertised class for which you have specific related experience/competence.  
Teaching certification is not required.  Applicants are contacted as needed for an interview.  Your proposal will be 
added to a database for consideration.  Proposals are reviewed on a quarterly basis.