Roxbury Community School Course Proposal Form

Contact Information:*

Instructor Name:
Company Name:
Phone Number (H):
Phone Number (C):
Phone Number (W):
Email:
Mailing Address:
City:
State:
Zip:
Affiliated Website:

2.	Name of Course:*

3.	Date(s):*

4.	Time(s):*

5.	Preferred Location: Please note if you need any special accommodations or needs such as technology, open space, etc.

6.	Description - 30 to 50 words at minimum:*

7.	Cost of Materials:* Please note whether the cost of the materials is provided by you, need to be purchased by the Community School, or whether participants need to purchase and bring with them to the class.

8.	Tuition Cost:* What is the tuition cost per person per course?

Community School Agreement Details*
What is the instructor fee, what is the Community School's Fee, etc. once costs are factored in? Example: 60 (instructor) /40 (community school), 80/20, 90/10 split

Instructor Fee:
Tuition Being Charged:

10.	Your bio for the RCS website:*

11.	Deadlines for Registration:*

12.

Required Enrollments:*
What is the class minimum and maximum? If this number is not met, the course will be cancelled.

Class minimum:
Class maximum:

13.

Fingerprinting Information:*
Please note that all instructors are required to have background check.

Has the instructor ever been fingerprinted for a NJ Public School?
If so, when?
If so, for what district?

	If you have a logo or graphic you would like posted on your course page on our website, please email it to arhodes@roxbury.org.