YCS Program Proposal/Application Form - 1st Time Instructor

INSTRUCTOR INFORMATION
Instructor's Name Instructor's Name First Last
Mailing Address Mailing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Cell Phone Cell Phone - ### - ### ####
Work Phone Work Phone - ### - ### ####
Home Phone Home Phone - ### - ### ####
Email

Confirm Email Address
What contact information may YCS staff give to class participants with questions?

What contact information may YCS staff give to class participants with questions? Cell Phone Home Phone Work Phone Email None
Please tell us more about your teaching experience and background.
Please give us the names and contact information of 3 references
Date of Birth Date of Birth / MM / DD YYYY
Legal Name Legal Name First Last
Town of Yarmouth / Yarmouth Community Services Background Check Authorization
By singing below I understand that in order to assess my qualifications for the position, a full criminal background investigation is necessary. I, therefore, authorize the Town of Yarmouth/Yarmouth Community Services to conduct an investigation in order to obtain information concerning my criminal background.

I understand that a consumer report may be prepared summarizing the above information. I may request a copy of any report that is prepared regarding me from the consumer reporting agency and may also request the nature and substance of all information about me contained in the files of the consumer-reporting agency. I understand that proper identification will be required and that I should direct my request to:

Equifax Credit Information Services, Inc
P.O. Box 740241
Atlanta, GA 30374

I hereby release any individual, entity and the municipality from all claims of liabilities that might arise from the inquiry into or disclosure of such information, including claims under any federal, state, or local civil rights law and any claims for defamation or invasion of privacy.

All the information and materials I have provided to the Town of Yarmouth as part of the employment process are accurate and truthful. I realize that providing the municipality with false information or intentionally withholding relevant information regarding my application may be grounds for dismissal.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
PROGRAM INFORMATION
Program Title

What do you want the name of your program to be?
What grades or ages is your program designed for?

What grades or ages is your program designed for? Pre-K Grades K-1 Grades 2-5 Grades 6-8 Grades 9-12 Adults Seniors Other Other
What day(s) of the week will yours program meet on?

What day(s) of the week will yours program meet on? Monday Tuesday Wednesday Thursday Friday Saturday Sunday Other Other
Select your requested program start date. Select your requested program start date. / MM / DD YYYY

Your program start date
Select your requested program end date. Select your requested program end date. / MM / DD YYYY

Your program end date
How many weeks will your program run?

Number of times your program will meet
List any dates you wish to skip within your program dates.

Please list the reason why for each date you need to skip unless its a school vacation or holiday.
Select your requested program start time. Select your requested program start time. : HH MM AM/PM

Program start time
Select your requested program end time. Select your requested program end time. : HH MM AM/PM

Program end time
Instructor Payment Information
I would like to be paid as:

I would like to be paid as: A YCS employee at an hourly rate (Rate determined by program fee, number of registrants and total hours worked) An independent contractor that provides my own insurance and receives 70% of program revenue
Select the total cost of the program (per person). $ Dollars . Cents
If you wish to volunteer, put $0.00.
IF YOU WOULD LIKE TO BE PAID AS AN INDEPENDENT CONTRACTOR

Multiply the total cost of the program by .70 to calculate the per person rate you will receive.

Please check that you have read and agree to the 70%/30% split and are able to provide proof of insurance. If you cannot provide proof of insurance, you must be paid as an employee at an hourly rate.

IF YOU WOULD LIKE TO BE PAID AS AN INDEPENDENT CONTRACTOR

Multiply the total cost of the program by .70 to calculate the per person rate you will receive.

Please check that you have read and agree to the 70%/30% split and are able to provide proof of insurance. If you cannot provide proof of insurance, you must be paid as an employee at an hourly rate. I Understand that 70% of the program revenue will go to the instructor(s) and 30% will go to YCS. I am able to provide proof of insurance.
IF YOU WOULD LIKE TO BE PAID AS A YCS EMPLOYEE

If you cannot provide your own insurance or do not qualify as an independent contractor, you must get paid as a YCS employee at an hourly rate. Your hourly rate will be determined by the program fee, total hours worked and the number of registrants we receive for your program.
Multiply the total cost of the program by .7 to calculate the per person rate you will receive.

Please check that you have read and agree to the 70%/30% split.

Multiply the total cost of the program by .7 to calculate the per person rate you will receive.

Please check that you have read and agree to the 70%/30% split. I understand that the 70% of the program revenue will go to the instructor(s) and 30% will go to YCS.
How many program hours with participants will you work?
How many program hours with participants will you work?
Comments to YCS staff about the above requested rate of pay

Optional
The YCS Refund Policy is as follows: Full refunds are given if a class/program is cancelled or rescheduled. If a participant withdraws at least 5 business days before the first class, they will receive a full refund. 50% refunds will be given if a participant withdraws 2-4 business days before the first class. No refunds will be given if a participant withdraws less than 2 business days before the first class.

The YCS Refund Policy is as follows: Full refunds are given if a class/program is cancelled or rescheduled. If a participant withdraws at least 5 business days before the first class, they will receive a full refund. 50% refunds will be given if a participant withdraws 2-4 business days before the first class. No refunds will be given if a participant withdraws less than 2 business days before the first class. I have read and understand the YCS Refund Policy
What is the minimum number of participants you need to run the program?
Must be a number greater than or equal to 2.
What is the Maximum number of participants you will allow?
Program Fee Waivers
YCS encourages each instructor to be willing to accept at least one 50% fee waiver per program.
How many 50% fee waivers are you willing to accept?

How many 50% fee waivers are you willing to accept? 1 2 3 4 Can't accept fee waivers Other Other
Please list any requests for special program equipment, needs or room requirements
Please supply a short paragraph that we can use in our activity guide to describe your program. OR you may upload a word document instead (see next question)

Descriptions may be edited by YCS staff.
Program description file upload

Attach Files

Descriptions may be edited by YCS staff.
Any notes or comments you want YCS staff to be aware of regarding you or your program proposal?
Web Site
Upload a File

Attach Files

YCS Program Proposal/Application Form - 1st Time Instructor

YCS Program Proposal/Application Form - 1st Time Instructor

INSTRUCTOR INFORMATION

PROGRAM INFORMATION

Instructor Payment Information

Program Fee Waivers YCS encourages each instructor to be willing to accept at least one 50% fee waiver per program.

Program Fee Waivers
YCS encourages each instructor to be willing to accept at least one 50% fee waiver per program.