1 day session 2 day session 4 day session 6 day session 8

CE Classes/ Courses Start Date

(Please put an ‘X’ the season(s) you would like to offer your course)

FALL, first week in October ___ SPRING, first week of February ___ SUMMER, first week of June ___

Instructor Name(s):

Address:

Telephone: Cell Phone: Email:

Class Title:

Class Size: (max): (min) Age Limits:

Course Length: (Please select session of choice with an ‘X’)

If OTHER, please explain: ___________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Class Length, (‘X’ ): 60 min____ 90 min ____ 120 min ____ 150 min ____ Other _______________

If other, please explain: _____________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Requesting Special Equipment /Location/ Furniture/ Supplies from Hutto ISD Community Ed:

(Please Explain):

Please return to:

HUTTO ISD Community Education

C/O Lizzy Samples 200 College St. Hutto, TX 78634

Telephone: 512.759.3771 ext. 1009 Email: [email protected].

1 Day Session _____ 2 Day Session _____ 4 Day Session _____

6 Day Session _____ 8 Day Session _____ OTHER: ____________

Instructions: Please complete the entire application. Attach additional pages if needed. Completed application includes: W9

(Preferred), Liability Insurance (Preferred), minimum of 3 reference letters (Mandatory) signed affidavit (Mandatory),

Background Check Form (Mandatory), Instructor Course Outline (Mandatory).

mailto:[email protected]

Supplies

Books/supplies purchased separately by students?

If supplies are needed, please attach a list to be included in the brochure or explained when registering.

Please write an exciting description of your class that can be used in the brochure. Be brief, but thorough.

This is how we sell your class! It is also how people decide whether the class meets their expectations.

For new courses, attach a course outline for our files – one page is fine. Please return to:



Telephone: 512.759.3771 ext. 1009 Email: [email protected].


Instructor Lesson Plan

This form should serve, as be template to assist when developing your Community Education camp or course.

(Please attach additional documents if needed)

Name of Course Name of Instructor(s)

Subject

Topic

Learning Objectives

Prerequisites of the Learner

Tools and Materials

A. Instructor

B. Student

PROVIDE OUTLINE OF CAMP/PROGRAM CURRICULUM EACH SESSION/DAY (Attach additional pages if needed)

Please return to:



Telephone: 512.759.3771 ext. 1009

Email:[email protected].



LEARNING ACTIVITIES (Lecture/ Demonstration/ Games)

MAJOR TOPICS

KEY POINTS

INSTRUCTOR GOALS FOR LEARNERS FOR CAMP/ COURSE (Attach additional pages if needed)

Please return to:



Telephone: 512.759.3771 ext. 1009 Email:

[email protected].


EMPLOYEMENT AFFIDAVIT (Required)

Pre-Employment Affidavit for Applicant Offered Employment The following affidavit is offered to satisfy the requirement of Texas Education Code section 21.009 for a pre-employment affidavit. For purposes of this affidavit:

Adjudication and conviction refer to a conviction, plea of guilty or no contest (nolo contendre), probation, suspension, or deferred adjudication.

Charge refers to a formal criminal charge as documented by a primary charging instrument (a complaint, information, or indictment) under the Texas Code of Criminal Procedure.

Inappropriate relationship refers to the crime of improper relationship between educator and student in Texas Penal Code section 21.12, and any other inappropriate relationship as determined by the State Board for Educator Certification.

I declare the following:

o I have never been charged with, adjudicated for, or convicted of having an inappropriate

relationship with a minor.

o I have been charged with, adjudicated for, or convicted of having an inappropriate relationship with a minor. The charge, adjudication, or conviction was determined to be false. The following are all of the relevant facts pertaining to the charge, adjudication, or conviction: .

o I have been charged with, adjudicated for, or convicted of having an inappropriate

relationship with a minor. The charge, adjudication, or conviction was determined to be true. The following are all of the relevant facts pertaining to the charge, adjudication, or conviction: .

I declare under penalty of perjury that the foregoing is true and correct.

(Signature of Declarant) (Date)

Name (First, Middle, Last)

Address (Street, City, State, Zip Code)

State of Texas County of

Before me, a notary public, on this day personally appeared , known to me to be the person whose name is subscribed to the foregoing document and, being by me first duly sworn, declared that the statements therein contained are true and correct.

(Personalized Seal) _

Notary Public’s Signature

Approved by the Texas Commissioner of Education, October 2017.

CRIMINAL HISTORY RECORD INFORMATION

AUTHORIZATION

Hutto ISD

Community Education Contractor

I authorize the Hutto Independent School District to obtain copies of any information

pertaining to any criminal history record maintained by any law enforcement agency and to

use said information for the purpose of evaluating my application for employment.

Signature Date

Section 22.083 of the Education Code authorizes a school district to obtain criminal history record

information from any law enforcement or criminal justice agency on applicants, employees, or volunteers of

the District.

Last Name:

Maiden/Former Last Name(s):

First Name:

Middle Name:

Social Security Number:

Driver’s License #: Issuing State:

Address:

City: State: Zip:

Date of Birth

Telephone Number, including area code:

Current E-mail address

1 day session 2 day session 4 day session 6 day session 8

Documents