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2. INSTRUCTOR CONTACT INFORMATION
4. First Name*
5. Last Name*
7. Mailing Address*
9. City*
10. State*
11. Zip*
13. Phone Number*
14. Email*
15. Emergency Contact*
17. Headshot
18. Short Bio
20. PROGRAM INFORMATION
22. Program Name*
23. Participant Age*
    -- Select One --Toddler (0-5)Child (5-11)Tween (11-13)Teenager (13-18)Adult (18+)Senior (60+)All Ages
24. Program Category *
    -- Select One --ArtsAthletic/FitnessCampsCraftsCulinaryEnrichmentHealth & WellnessPresentationSportsTechnologyTherapeutic Recreation
26. Program Description*
27. Participant Receipt Notes
29. Class Minumum*
30. Class Maximum*
31. Program Location*
    -- Select One --PLC GymPLC Training RoomPLC StagePickleball CourtBasketball CourtRectangle FieldDiamond FieldParkTrailPicnic PavilionOutdoor ClassroomOther (describe below)
32. Room Set-up*
    -- Select One --ClassroomConferenceU-ShapeTheater (no tables)Table Pods (4 or 6)Open Floor (no tables/chairs)Other (describe below)
34. Additional Information
36. Class Supplies

    The instructor is responsible for obtaining and supplying all materials, supplies, and equipment necessary to provide the service as agreed on in the instructor agreement. Any supplies needed for a class/program will be the responsibility of the instructor to describe below and must be pre-approved by the Recreation Programmer. If supplies are to be obtained by the participant, it will be the responsibility of the instructor to include a supply list ton this form. Any materials and supplies purchased for programs must be discussed and agreed upon in advance.

38. Instructor will Provide*

    1. Handouts
    2. Power Point presentation
    3. All class supplies
    4. Some class supplies (indicated below)
39. Rec Staff will Provide*

    1. Tables
    2. Chairs
    3. AV Equipment
    4. Projector

    1. Copies of Handouts
    2. Sport Equipment
    3. All class materials
    4. Some class materials

    Specify equipment needed below

41. Materials Instructor will Provide*
42. Materials Parks & Rec will Provide*
44. INSTRUCTOR PAYMENT

    Instructors are paid by check, and contractual statements are performed monthly. All instructors will meet with the Recreation Programmer to discuss details on payment and amount. Instructor payment can be hourly, 80% of class fees, or a flat fee per person/class. A W-9 form must be submitted at least two weeks before the class date to enter the vendor into the County’s financial system.

46. Instructor Fee*
47. Fee Type*
    -- Select One --PercentHourly RateFlat RateAmount Per Student
48. Material Fee
50. INSTRUCTOR PAPERWORK

    Instructors are asked to provide the following paperwork:

52. Copy of Photo ID
53. Completed W-9
54. Certificate of Insurance (vendors only)
56. CPR Certification
57. First Aid Certification
58. Other Certification
60. INSTRUCTOR TERMS & CONDITIONS

    Conditions for Contracting & Volunteering

    For the protection and ensured welfare and safety of ALL participants, it is the policy of the County of Powhatan and the Parks and Recreation Department to conduct a criminal background check on all prospective volunteers and contracted personnel. The background check paperwork should be submitted to Recreation program staff immediately. In signing the separate document the instructor gives the Department permission to proceed with the criminal background check and to take all action necessary to access such information and thereby releasing the County of Powhatan, Parks and Recreation Department, and County of Powhatan employees from any damages or liability resulting from said background check. 

    All instructors and volunteers will undergo verification by the Powhatan County Human Resources Department and the respective Department Director to confirm eligibility. Individuals with prior employment separations from the County that include termination, resignation under adverse circumstances, or other actions that place them in poor standing with the County or Department are not eligible to serve as instructors or coaches.

    Independent Contractor:

    It is understood that the instructor is acting as an independent contractor or volunteer and not an agent or employee of the County of Powhatan or the Department and is therefore not eligible to lay claim to benefits from retirement, Social Security, Unemployment Insurance, Workers Compensation, or to those benefits reserved for employees of the County of Powhatan or the Department. The instructor is responsible for paying their own medical bills for any personal illness or injuries occurring during their contract term. 

    Assignment:

    The instructor shall not, under any circumstances, obtain a substitute or assign the Contract or its duties without proper written authorization from the Department. Should such authorization be granted, the instructor agrees to inform any substitute or subcontractor of all the stipulations of their contract. It is the responsibility of the instructor to compensate the substitute or subcontractor. 

    Hold Harmless:

    The Instructor agrees to save, defend, hold harmless, and indemnify the County of Powhatan and all of its officers, departments, agencies, agents, and employees from and against any and all claims, losses, damages, injuries, actions, fines, penalties, costs (including court costs and attorney's fees), charges, liability, or exposure, however caused, resulting from, arising out of, or in any way connected with the Instructor's negligent or wrongful acts, errors or omissions in the performance or nonperformance of its work called for by the Contract, including such acts, errors or omissions of Instructor’s employees, servants or agents. 

62. SIGNATURE

    I have read and agree to the terms and conditions listed above.

64. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
66. Electronic Signature
Leave This Blank:


68. 1. Receive an email copy of this form.
69. Email address

    This field is not part of the form submission.

70. Submit

* indicates a required field