2008-09 Junior Achievement Program Class Request Form

To request JA curriculum and a trained volunteer for your classroom, please complete and submit this form.  All information on this form is required. Please note that JA uses this information solely for its internal purposes and does not release individual addresses or other identifying information to outside parties for any reason.  (NOTE:  If you are interested in providing JA programming to multiple classes, i.e., if you teach 3 sessions and are requesting JA for all three classrooms, please complete this form for EACH CLASS or contact Cindy Bazner at 313-962-5689 to make arrangements.)

School Information

Name of Your School:  

School District:  
School Address:  
 
City:    State: MI Zip:  
County:                    <-- Make Selection -->WayneOaklandMacombWashtenawMonroeLivingstonShiawasseeGeneseeLapeerSt. Clair 
  
School Phone:        School Fax: 
 
Principal's Name:   
 
School Liaison, if any:   

Teacher Information

Title: Dr. Mrs.  Ms. Mr.       
Gender (for survey purposes only): Female: Male
Teacher's First Name:   M.I.:  
 
Last Name:   

Home Address:    
City:    State: MI  Zip: 
 
Work E-Mail:   
 
Personal E-Mail:   

Please check preferred method(s) to contact you:

Work E-Mail    Personal E-Mail     Direct Phone      Home or Cell Phone

Best time of day to contact you?: 

Requested Program 

(Suggested Grade Placement; choice is at teacher's discretion) 
*Indicates program is appropriate for students in middle school or high school
Elementary School Programs:  <-- Make Selection -->Ourselves (K)Our Families (Grade 1)Our Community (Grade 2)Our City (Grade 3)Our Region (Grade 4)Our Nation (Grade 5) 
Middle School Programs:        <-- Make Selection -->JA Global Marketplace (6th to 8th Grade)JA Economics for Success (6th to 9th Grade)JA America WorksJA Job Shadow (7th to 12th Grade)JA It's My Business (After School Program)Rock Rinancial JA Finance Park
High School Programs:           <-- Make Selection -->JA TitanJA Success SkillsJA EconomicsJA Company*JA Job Shadow (7th to 12th Grade)Rock Financial JA Finance Park (7th - 10th Grade)JA Presents: NEFE H.S. Financial PlanningJA Careers With a Purpose (Pilot)JA Global Business Ethics (Pilot)JA Banks in Action (NEW!) 
Grade Level of Your Class?                   
No. of Students Enrolled in this Class?   

Additional Information

(Optional) If you have a preference for scheduling this JA class (available September through May), please rank your top three choices:
1st Choice:  
2nd Choice:   
3rd Choice:         
(Optional) If you have a JA Consultant preference, please provide his/her name, firm and phone (if known):
Consultant Name:  
Firm:   Phone:  

The value of JA averages $1,000 per class.  Given the economic climate in Michigan we have seen a decline in donations.  Any funding your school, parents or business partners can assist with will be greatly appreciated and will allow us to provide JA Programs to more students.  Please indicate how we can count on your support and/or participation to help bring JA to your classroom this year.