Prospective Instructor Survey Thank you for interest providing classes with St. Mary's County Recreation & Parks. In order to meet the needs of our community and match with your interests and skills, please provide us with as much detail as possible on this form. This will assist our Program Coordinator to understand your class proposal and begin to develop the contract for fees and scheduling.If you have any questions, please contact us at 301-475-4200 ext. 1800, Monday-Friday, 8:00am-5:00pm. You may also email us at webtrac@stmaryscountymd.gov. Question Title * 1. Contact Information: Name Company Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Email Address Phone Number Question Title * 2. Please select the type of class/program you'd like to offer: Animals & Pets Arts & Crafts - adults Arts & Crafts - youth Dance - adult Dance - youth Education & Development Fitness - adult Fitness - youth Music Outdoor Recreation Self-Defense Special Interest Therapeutic Trip Leader - organized bus trips Other (please specify) Question Title * 3. Class Description: Please provide details that will be advertised to the participants so they know what to expect from the class. Question Title * 4. Learning Outcomes: Please indicate the goals of class and what the participant should expect to gain from attending. Question Title * 5. Class Format Number of Classes Frequency Desired Days Desired Times Type of Facility Age of Participants Minimum Participants Maximum Participants Supply Fees Question Title * 6. Please indicate your totals of years of experience teaching this topic: Question Title * 7. Please provide a list of any relevant certifications or special education/training: Question Title * 8. Which locations are you able and willing to provide this class? Please check all that apply and understand this does not obligate you to any particular location at this time. Carver Recreation Center - Lexington Park Chancellor's Run Regional Park & Loffler Center - Great Mills Hollywood Recreation Center - Hollywood Leonard Hall Recreation Center - Leonardtown Wellness & Aquatics Center (Leonardtown Campus of College of Southern Maryland) Margaret Brent Recreation Center - Mechanicsville St. Mary's County Public Schools - North end of county St. Mary's County Public Schools - Central portion of county St. Mary's County Public Schools - South end of county My Business Location Other (please specify) Done