JA Programs Teacher Agreement

Choose One*

I am flexible and can host a JA volunteer at any time throughout the school year.I prefer to receive a JA volunteer during a particular month.

Month Preferred

*Please note: Choosing this does not guarantee you will receive a volunteer during the preferred month, however, we will do our best to fulfill this request.

Full Name*

First NameLast Name

School Name*

School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

School Phone*

Area CodePhone Number

Cell Phone

Area CodePhone Number

E-mail*

Preferred Method of Communication

Gender

MaleFemale

Ethnicity

Have you had a JA program in your classroom before? *

YesNo

Is this an after school program?*

YesNo

We are required by JA USA to collect ethnicity data on students who participate in JA programs as part of an after-school program. Please fill in the number of students for each category below:

African American

Asian

Pacific Island

American Indian

Hispanic/Latino

Caucasian

Other

Do you teach in Elementary, Middle or High School?*

Elementary SchoolMiddle SchoolHigh School

Grade*

Planning Period*

Lunch*

Ideal time for volunteer to visit:

Please inform us of any ELL, Special Needs, or other information we may need to know about your classroom:

JA Programs Available

Elementary K-5*

Please select a program according to grade level

JA Program Requests

Please specify the following for each class section in which you would like the JA program to operate, noting semester changes and if you operate on A/B scheduling. (Example: Program: JA Career Success, Day/Time: 10-10:50 A Day, Fall; Program: JA Careeer Success, Day/Time: 11:05-11:55 A Day, Fall; etc.)

*Please note: Volunteers are assigned based on availabilty and could mean not all classes will receive a JA volunteer. Also, please be prepared to coordinate shcedules with different volunteers for each program request.

Class Period (Day/Time)*

Program Name*