<p> NORTHAMPTON TOWNSHIP PARKS AND RECREATION DEPARTMENT PROGRAM PROPOSAL Name of Program______Proposed by ______Date submitted______</p><p>Program Instructor ______(First) (Last) Address______(Street) (City/Area) (State) (Zip code) Phone (H) ______(W) ______(C)______Instructor training/experience:______Program Description (utilized for promotional materials)______</p><p>Explain program content …goals, benefits, skill development etc. (weekly if applicable): ______Number of days you are available ______List days ______Times______</p><p>Target age group______Enrollment : MIn. ______Max. ______N/A______Office Use: Program will be scheduled: Days per week Weeks per session _____ </p><p>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______</p><p>E.R.S. fee: R fee : NR fee: Materials fee:______</p><p>Discounts______Requested Room requirements:</p><p>Size of room______Number of tables and chairs______</p><p>Any special requirements? sink, gym, stage, etc?______</p><p>Materials Fee:$ List materials______</p><p>List equipment required for the class______</p><p>Rate of pay requested : Hourly rate $ Percent of enrollment Other ______</p><p>Make checks payable to: ____</p><p>______</p><p>______</p><p>Office Use:</p><p>Approved Rate of pay:______</p><p>Mail completed form to : Northampton Park & Recreation 55 Township Road Richboro, Pa. 18954 357-6800 Ext. 249</p>