Northampton Township Parks and Recreation Department

NORTHAMPTON TOWNSHIP PARKS AND RECREATION DEPARTMENT PROGRAM PROPOSAL Name of Program______Proposed by ______Date submitted______

Program Instructor ______(First) (Last) Address______(Street) (City/Area) (State) (Zip code) Phone (H) ______(W) ______(C)______Instructor training/experience:______Program Description (utilized for promotional materials)______

Explain program content …goals, benefits, skill development etc. (weekly if applicable): ______Number of days you are available ______List days ______Times______

Target age group______Enrollment : MIn. ______Max. ______N/A______Office Use: Program will be scheduled: Days per week Weeks per session _____

Day(s) Date(s)______Holidays Time ______Class # ______Day(s)______Date(s)______Holidays Time ______Class #______Day(s)______Date(s)______Holidays Time ______Class # _____ Day(s) Date(s)______Holidays Time ______Class # ______Day(s)______Date(s)______Holidays Time ______Class #______Day(s)______Date(s)______Holidays Time __ Class # _____ Location:______Room______

E.R.S. fee: R fee : NR fee: Materials fee:______

Discounts______Requested Room requirements:

Size of room______Number of tables and chairs______

Any special requirements? sink, gym, stage, etc?______

Materials Fee:$ List materials______

List equipment required for the class______

Rate of pay requested : Hourly rate $ Percent of enrollment Other ______

Make checks payable to: ____

______

Office Use:

Approved Rate of pay:______

Mail completed form to : Northampton Park & Recreation 55 Township Road Richboro, Pa. 18954 357-6800 Ext. 249