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2. 
3. Contract Class Proposal Application
5. GENERAL INFORMATION
7. First Name*
8. Last Name*
10. Address1*
12. City*
13. State
14. Zip*
16. Social Security # or Tax ID #
17. Email Address:*
19. Day Phone:*
20. Evening Phone:*
22. CA Drivers License # (if applicable)
23. Expiration Date
25. Business License # (if applicable)
26. Expiration Date
28. Have you ever been convicted of any charges other than minor traffic citations? *
30. List and discuss any convictions: (N/A) if this does not apply *
34. QUALIFICATIONS
36. Education
38. List highest High School Grade Completed *
40. College/University Attended
42. Dates Attended
43. Major
44. Degree
46. Current or Recent Experience Related to Proposed Class
48. Employer *
49. Phone *
50. Dates Employed*
51. Job Title*
53. Professional training, certifications, licenses related to proposed class:*
57. CLASS PROPOSAL
59. Class Title:*
61. Class Description:*
63. CLASS SPECIFICS
65. Targeted Age Group:*
66. Number of classes per week:*
67. Number of weeks per class:*
69. Total number of class meetings:*
70. Preferred class day(s):*
71. Preferred class time(s):*
73. Minimum number of Students:*
74. Maximum number of students: *
75. Proposed Class Fee:*
77. Additional Materials Fee:*
78. Desired location:*
79. Proposed start date:*
81. Are you requesting to use a City Facility? *
83. a. If no, where do you plan to teach this class?
85. b. If yes, what are your proposed facility request:
87. Number of tables:*
88. Number of chairs:*
89. Are electrical outlets needed:*
91. Would you be able to provide a $1,000,000 liability insurance policy naming the City of Colton additionally insured? *
93. REFRENCES
95. Contact Person: *
96. Title: *
97. Phone Number:*
99. Contact Person*
100. Title*
101. Phone Number*
103. Contact Person*
104. Title*
105. Phone Number*
107. I, the undersigned, agree to indemnify and hold the City of Colton, its officers, agents and employees harmless from and against any and all liability resulting in injury which may be suffered by me arising out of or in any way connected with my participation in the conducting of the above listed activities at City of Colton facilities, save and except for the sole negligence or intentional misconduct of the City or its employees. It is understood and agreed that there is no relationship of employer-employee for Worker’s Compensation purposes between the City of Colton and me or any other person connected with me in conducting the above listed activities unless, such person is otherwise regularly employed by and conducting official business of the City of Colton.
109. Sign Name:*
110. Date:*
     Date:

     Date:
Leave This Blank:


112. 1. Receive an email copy of this form.
113. Email address

     This field is not part of the form submission.

114. Submit

* indicates a required field