Instructor and Activity Leader Form

Northern York Community Services Foundation

Instructor and Activity Leader Information Form

Name (first, MI, last):			Thank You!
Mailing Address
Street:		Home Phone:
City:		Work Phone:
State:	Zip:	Cell Phone:
E-mail:
Day (s) of week available (select all that apply):
Time of day available
Day at o'clock		Evening at o'clock

Name of course or activity you would like to teach or organize:
Brief description of course or activity:
Experience and/or education related to course or activity topic:
If working with minors you may need to acquire The Pennsylvania State Police Request for Criminal Record Check and the Pennsylvania Child Abuse History Clearance.