Fillable Instructor Interest Form (City of Chandler)

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Instructor Interest Form (City of Chandler)

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Page 1 Revised: 3/6/17
City of Chandler Recreation Division
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The City of Chandler Recreation Division is always looking for quality instructors to enhance the variety of classes
and workshops offered throughout the year at its many facilities. Recreation Coordinators work with individuals and
businesses (contractors) on an agreement basis. For individuals, agreements are renewed on a season-by-season
basis. For contractors, agreements are renewed annually.
Recreation Coordinators evaluate potential classes on demand/interest, facility availability, and cost. Instructor
Interest Forms are kept on file for one (1) year and are referred to when new Instructors are needed. Recreation
Division staff are dedicated to making the instructor’s teaching experience enjoyable and rewarding.
Please complete this form and return it to:
City of Chandler Recreation Division * Mail Stop 501 * P.O. Box 4008 * Chandler, AZ 85244-4008.
GENERAL INFORMATION
To become an instructor, an individual/contractor must possess strong teaching skills; be positive, prompt,
organized, and dependable; have good communication skills; and demonstrate a desire to promote the City of
Chandler Recreation Division’s mission. The Recreation Division is interested in classes and programs that are
unique or fill a specific community need. Program selections are based upon the instructor’s qualifications and
experience, need for and marketability of the program, facility availability, and ability to coordinate class dates and
times.
NAME:
Last First Middle Initial
ADDRESS:
Street Apt. No. City/State Zip
BUSINESS NAME: EMAIL ADDRESS:
HOME PHONE: WORK PHONE:
EDUCATION, TRAINING, AND SKILLS:
Do you have a High School diploma or GED? Ye s No If no, indicate highest grade completed:
Education from an Accredited College/University:
College/University
Major/Degree
Degree Completed
If no degree, number of credit hours
Prior Instructor Experience:
Describe any other training or special skills:
Please provide a copy of all pertinent certifications held.
Page 2 Revised: 3/6/17
SEASON(S) YOU ARE INTERESTED IN TEACHING (YOU MAY CHOOSE MORE THAN ONE):
Winter (December, January, February)
Spring (March, April, May)
Summer (June, July, August)
Fall (September, October, November)
AVAILABILITY (check all boxes that match when you are available to instruct):
Monday
Wednesday
Sunday
Mornings
8 a.m. – Noon
Afternoons
Noon – 5 p.m.
Evenings
5 – 10 p.m.
LOCATION WHERE YOU WOULD LIKE TO TEACH (YOU MAY CHOOSE MORE THAN ONE):
Community Center, 125 E. Commonwealth Ave.
Environmental Education Center at
Veterans Oasis Park, 4050 E. Chandler Heights Rd.
Senior Center, 202 E. Boston St.
Snedigar Recreation Center, 4500 S. Basha Rd.
Tennis Center, 2250 S. McQueen Rd.
Tumbleweed Recreation Center,
745 E. Germann Rd.
Why would you like to become an Instructor with the Recreation Division?:
All individuals, contractors, and contractors’ employees must successfully pass a background check that reveals no
conviction or other adverse disposition for any crime against persons or property, or any crime involving fraud,
dishonesty, or moral turpitude.
Have you ever been convicted and/or placed on probation for any criminal offenses? Yes No
If "yes,” please provide dates and detailed information (including minor offenses):
(A "yes" answer will not automatically disqualify you. Each case will be considered individually, based on program requirements.)
Please list the names of three (3) people that can speak to your abilities/qualifications:
Organization: Name:
Location: Years:
Phone: Relationship:
Organization: Name:
Location: Years:
Phone: Relationship:
Organization: Name:
Location: Years:
Phone: Relationship:
Page 3 Revised: 3/6/17
City Chandler Recreation Division
CLASS PROPOSAL
Instructor: Suggested Class Title:
Requested Facility: Suggested Class Price (Contractors Only): $
Suggested Hours: Suggested Day: Suggested # of Weeks:
Ages (circle): 0-2 2-3 3-5 6-8 9-11 12-15 16+ 18+ 55+ other:
Class Size (circle): 6-8 8-10 10-12 15-20 20-30+ other:
Suggested Class Description (MAXIMUM 125 words):
List up to three (3) outcomes, by priority, using measurable action phrases such as define, name, demonstrate,
analyze, etc. “As a result of their experience in this class, participants will be able to”:
1.
2.
3.
How will the above outcomes be measured? A Success is defined as:
1.
2.
3.
Materials Being Requested (type of space, equipment, tables, chairs, A/V, mats, etc.):
Page 4 Revised: 3/6/17
Week-by-week Curriculum
Week 1:
Week 2:
Week 3:
Week 4:
Week 5:
Week 6:
Week 7:
Week 8:
Page 5 Revised: 3/6/17
City Chandler Recreation Division
CLASS SUPPLY FEE FORM
Supply Fee is paid directly to the Instructor and is in addition to the class Registration and/or Instructor fees. It
is the Instructor’s responsibility to collect the fee from students to use it for the sole purpose of purchasing
supplies for the class. If students must provide their own supplies, Instructors are required to provide a Supply
List with the Class Proposal Form that will be provided to students upon registration.
Instructors who will be charging a supply fee will need to complete the information below indicating the supply
name, what it will be used for, and the cost broken down per student. Instructors may not use the copy
machines at the recreation facilities. All printing is the responsibility of the Instructor and costs must be
included in the Supply Fee. Instructors must submit copies of the receipts from supply purchases by the
second-class meeting. Any other necessary supplies not listed on the Supply Fee form will need to be
supplied by the Instructor at their own expense.
Supply
Use
Cost/Student
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Total Cost Per Student:
$
Page 6 Revised: 3/6/17
City Chandler Recreation Division
INSTRUCTOR ACKNOWLEDGEMENT
Successful Instructor Interest Forms will demonstrate that the Instructor agrees to:
• Act professionally while representing the City of Chandler and do nothing, which would bring discredit
upon the City of Chandler.
• Never use or attempt to use City of Chandler or City of Chandler Recreation Division logos or City
issued equipment or any article giving reference to the City of Chandler inappropriately.
• Provide accurate information at all times during service.
• Always treat fellow instructors, City officials, City employees, and members of the community with
respect and dignity.
By signing this Instructor Interest form, I certify that all information is true and correct to the best of my
knowledge, and any omissions or misrepresentations will be cause for refusal of placement or immediate
dismissal at any time during the period of my placement. I give the City of Chandler Recreation Division
authorization to investigate all matters contained in this application. I understand that it is my responsibility to
keep the Recreation Division advised about any changes of address or phone number. I agree to obey all
rules and procedures established by the City of Chandler Recreation Division, and understand that being an
instructor means I have made a commitment to the program. I further understand that I am a not an employee
of the City of Chandler and therefore not entitled to any benefits which are provided to employees of the City of
Chandler. I will assume all risks and/or hazards associated with participation in this program and do hereby
agree to hold harmless the City of Chandler and/or its employees.
Signature Date
Please return completed form to:
City of Chandler Recreation Division * Mail Stop 501 * P.O. Box 4008 * Chandler, AZ 85244-4008.
For more information, call the Chandler Recreation Division at (480) 782-2727.
Thank you for your interest in collaborating with the City of Chandler Recreation Division.
OFFICIAL USE ONLY: STAFF NAME: DATE RECEIVED: / /
AP P R O VED: DATE: / / DENIED: DATE: / /
NOTES:
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Instructor Interest Form (City of Chandler)

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Completed 14 July 2020

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