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2. Name*
4. Primary Phone*
6. Email*
8. Business Name
10. Website Link
12. Address1*
14. Address2
16. City*
17. State*
18. Zip*
20. Proposed Class Title*
22. Description of Class*
24. Age/Grade Population to be Served*
26. Proposed Length of Class(es)*
    Please include desired # of weeks if applicable, desired day(s) of the week, and desired time during the week.
28. Proposed Season(s)*

    1. Spring
    2. Summer
    3. Fall
    4. Winter

    Please check all that apply
30. Are you or any other class instructor CPR/First Aid certified?
32. Can you provide a recent background check or willing to take one if necessary?*

    1. Yes
    2. No
34. Program able to accommodate handicap needs?*
    ADA laws require programs must be able to make accommodations for handicap needs. Please explain.
36. Materials Needed for Class?*
    Please also include whether or not materials are already included or to be brought by participants.
38. Classroom Requirements*
    Please indicate what type of space, tables & chairs, audio/visual equipment (if applicable) you need for this course.
40. Instructor Rate
42. Recommended Class Fee
44. Attachments
    Please attach resume, weekly syllabuses, program policies, pictures, etc. relevant to program proposal.
46. Signature*
    On behalf of this program, I understand all procedures, policies and rules associated with this request and accept legal and financial responsibilities involved in the use of any Cherry Hill Township facilities and/or equipment. Please type name above.
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48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit

* indicates a required field