Program Proposal Form

Program Administrator

First Name

Last Name

Program Proposed

Program Description

Please provide a detailed write-up

Dates/Times Requested

Requested Start Date

Requested End Date

Requested Start Time

(hh:mm am/pm)

Requested End Time

(hh:mm am/pm)

Space Requested (optional)

Space Requested

Equipment Required

Please list any materials or equipment required

Target Audience and Distribution

What ages is this program for and how would you like the information distributed?

Enrollment Information

Enrollment Info - Min

Minimum Number of Participants

Enrollment Info - Max

Maximum Number of Participants

Staffing

All staff must complete a CORI form at least 3 weeks prior to the start of any program

Requested Salary

If different from the established rate of $40 an hour

Suggested cost of the program and what does it include?

Suggested Cost

Price Includes

Any additional Information

Additional Info

Please list any additional information you would like us to request on the registration form. (ie t-shirt size, required equipment, etc.)