Leisure Course Proposal Application

Room Needs /Miscellaneous:

Other (list below)Dry Erase Board StereoTV/VCR/DVD

COURSE INFORMATION

Title of Class:

SundayPreferred Meeting Day(s): Monday Tuesday Wednesday Thursday Friday Saturday

Alternate Meeting Day(s): FridayThursdayWednesdayTuesdayMondaySunday

Preferred Class Time: Alternate Class Time:

Preferred Class Date(s) for Session I Alternate Class Date(s) for Session I

Start Date End Date End DateStart Date

End DateStart DateEnd DateStart Date

Alternate Class Date(s) for Session IIPreferred Class Date(s) for Session II

Maximum Number of Students:

Minimum / Maximum Age Requirements, If Any:

Saturday

HSU Student CourseFee per Session:

Drop-in Fee (if offered):

Are students responsible for purchasing supplies for this class? Yes No If yes, estimated cost of supplies:

NoYesWill you be collecting a materials fee at the first class meeting? If yes, estimated cost of materials:

Overhead Projector

ParticipantPrerequisites, If Any:

Cell PhoneEmailWhat information (if any) can be given out to inquiring students? Home Phone

What is the best way for the Program Coordinator to contact you? Email Cell Phone Home Phone Mail

Instructor's Name

Date

Semester Applying for

University Center Agreement Employee Indepent ContractorWhich are you applying for?

INSTRUCTOR INFORMATION

Minimum

EmailPrimary Phone Number

Instructor Signature: _____________________________________________________ Date: ________________________

CERTIFICATION

JOB / CLASS RELATED REFERENCES:

Title:Reference 1 Name:

Mailing Address:

Length of Employment:

Zip:State:City:

Company Name:

Phone Number: Email:

Mailing Address:

Phone Number:

Company Name:

Reference 2 Name:

Length of Employment:

Title:

Zip:State:City:

Email:

Mailing Address:

Phone Number:

Company Name:

Reference 3 Name:

Length of Employment:

Title:

Zip:State:City:

Email:

Catalog Description (50 words or less), Website description (150 words or less) and Instructor Biography (100 words or less)

Please be sure to include the following information with this completed Leisure Class Proposal Application:

Class Outline / Letter of Intent

Instructor Resume

Under penalty of perjury, I certify that the information provided on this form and included in this application packet is true,correct and complete.

OFFICE USE ONLY

NoYesPacket complete?

Interviewed? Yes No No (if no, explain below):Proposal Accepted? Yes

Do you have any assistant / substitute instructors for your class? No Yes - contact information is provided below:

Instructor Name: Email:

Home Phone: Cell:

Mailing Address: City: State: Zip:

Leisure Course Proposal Application