Class Registration Form

Teacher Name:   County:

School:  Program Requested: 

Work Phone: Fax: E-mail:

Cell Phone: Home Phone: Preferred Method of contact: Please select School Phone Email Home Phone Cell Phone Fax

Preferred Month: Sept.-Nov. Oct.-Dec. Jan.-March.  Feb.-April    Other:

Lunch time: Room #: Is your class: Regular Ed    Other:

Teacher's Gender: Please Select Female Male     Teacher's Ethnic Origin: Please select African American Alaskan Native American Indian Asian Caucasian Hawaiian Hispanic  

Demographic information collected by JA is used for statistical purposes only. It is not used for individuals, but used only in aggregate form. JA is a non-profit organization that applies for grants and funding from various entities. In these applications, we need to provide statistical information to demonstrate that JA reflects the diversity of the communities we serve.  We appreciate your assistance in ensuring JA’s continued service to our children.

 

Grade Level	Period & Time of Class	# of total students	Asian/ Pacific Islander	Amer.Indian/ Alaskan	Hispanic	African American	Caucasian	Multi-racial

 

Please provide names of individuals who would be interested in teaching JA to your class.

 

Name:   Daytime Phone:

Name:   Daytime Phone:

 

Please indicate the days and times you would prefer to have your Junior Achievement Program:

 

Mondays Tuesdays Wednesdays Thursdays  Fridays   Time:

 

Please provide any additional information that would assist your JA volunteer teaching your class: