Teacher Profile and Program Request Form

Complete the online form below and click submit
Fields in red are required.
Only one class/teacher per form, please.

SECTION 1: Teacher Information

Have you ever had JA in your classroom before? Yes No

Are you at a different school this year?YesNo

First Name: Last Name:

Salutation: <-- Make Selection --> Dr. Mr. Ms. Mrs. Gender: <-- Make Selection --> Male Female

School: District:

Ethnicity: Black/African American American Indian Asian White/Caucasian Hawaiian Hispanic Multi-Racial Information not provided

Home Phone Number:

Cell Phone Number:

Work Phone Number: Work Extension:

Fax Number:

School Mailing Address:

Home Mailing Address:

Email Address:

Preferred Method of Contact: <-- Make Selection --> Email Work Phone Home Phone Cell Phone Fax Mail

SECTION 2: Class Information

School Year: 2011 - 2012:  2010 - 2011

Expected Number of Students: Grade: K 1 2 3 4 5 6 7 8 9 10 1 12

Select JA Program for a Volunteer to teach in your classroom: <-- Make Selection --> Ourselves (K) Our Families (1st gr.) Our Community (2nd gr.) Our City (3rd gr.) JA More than Money (3rd - 5th gr.) Our Region (4th gr.) >JA BizTown curriculum and trip to JA World (4th - 7th gr.) JA BizKids(4th - 8th gr.) Our Nation (5th gr.) JA It's My Business (5th - 9th gr.) America Works (6th - 8th gr.) JA Economics for Success (6th - 8th gr.) JA Global Marketplace (6th - 8th) JA Job Shadow (6th - 12th gr.) JA Finance Park curriculum and trip to JA World (7th - 10th gr.) JA Be Entrepreneurial (8th - 12th gr.) NEW 2009! JA Business Ethics (8th - 12th gr.) JA Careers with a Purpose (8th - 12th gr.) JA Company Program (8th - 12th) JA Success Skills (8th - 12th gr.) JA Titan (8th - 12th ) NEFE High School Financial Planning Program (8th - 12th gr.) JA Exploring Economics (9th - 12th gr.) <JA Economics – see Econ. Section below to order textbooks (9th - 12th)      

Note: If you are a High School Economics teacher who will be using the textbook series JA Economics, only then must you complete Section 3. Otherwise, continue to section 4.

SECTION 4 -- Scheduling & Volunteer Info.

School Year:  2009-2010:  2010-2011: 

Semester:  <-- Make Selection --> Fall Spring Either

Room #:   

School Level:  Elementary School  Middle School  High School  Mixed Level (ie. Intermediate)

Delivery Method:
  JA in a Day for K-5th gr. (complete program in 3-4 hours on one day)
  1x/week for 5 weeks (45 min.per visit)
  Either
  Don't Know

Is there a specific volunteer you'd like to request? If so, what is the volunteer's name?: 

Are you able to recruit a volunteer from your classroom parents,
student teacher, or school community?  

Are there any dates when you prefer to have a volunteer?
If so, when?: 

Does your classroom have any special characteristics (ie ESL, Special Needs, Gifted):