Elementary Class Request Form
Please Complete One Form per Teacher
Teacher Name (First & Last) *
Your answer
Teacher Home Address: *
Your answer
Teacher Home City - State - Zip *
Your answer
Teacher Mobile/Home Phone *
(Other than school number)
Your answer
Teacher Email Address *
(Best email address to reach you)
Your answer
School *
Your answer
Subject Area & Grade *
Your answer
Site Principal Name: *
Your answer
District Superintendent Name *
Your answer
Ethnicity: *
Teacher data - for grant purposes only
Gender *
Teacher data - for grant purposes only
Please select your program.
Select Your Program Below *
# of Classes *
Your answer
# of Students per Class *
Your answer
During what semester would you like your JA program? *
If you've had JA programs in your classroom in the past and would like to invite a specific volunteer back to your class, OR you would like to recommend a new volunteer to teach in your classroom, please list him/her below.
(Volunteer Name and Email/Phone Number)
Your answer
Additional comments:
Your answer
Teacher Agreement:
By entering your name and today's date at the bottom of this form, you agree to the Teacher Agreement outlined below.
I understand that by requesting this program Junior Achievement will purchase the needed materials for my students and begin to recruit and train volunteer consultants for my class. When I receive my volunteer contact information, I will contact my volunteer immediately to arrange a schedule suitable for their work schedule and my classroom schedule or talk about the JA in a Day schedule. The program consists of 5-6 visits to the classroom for about 30-45 minutes to be completed during the school semester or JA in a Day. I understand that JA has committed funding for the curriculum and the completion of this JA class. I will notify the Junior Achievement office immediately of any problems.

I ACCEPT THE RESPONSIBILITY TO REMAIN IN THE CLASSROOM WITH MY JUNIOR ACHIEVEMENT VOLUNTEER AT ALL TIMES.
Teacher's Name *
Your answer
Today's Date *
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