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Town of Essex

Recreation and Culture

Organization Name:

Instructor First Name

Instructor Last Name

Contact Phone Number

Email Address:

Please summarize your qualificatons relevant to the program you are proposing.

Name of Proposed Program

Age Range of Participants

Maximum Enrollment

Description of Program (Please submit a weekly summary of the program also):

Indicate Program Type:

Daily

Weekly

Special Event (Once)

Other

Requested Dates/Times (Please list in order of preference):

Please provide a summary of required materials:

Additional Information:

Please attach the file you wish to submit (max 2MB)

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