Request Form

Middle & High School Class Request Form
Please Complete - One Form per Teacher

Teacher: School:

Home Address: School Address: School Fax #:

E-mail: Home #: School #:

Subject/grade level: Planning Period:
Ethnicity: African American: American Indian: Asian: Caucasian: Hawaiian/Pacific Islander: Hispanic: Multi-Racial: No Response

PLEASE
Specify below which program(s) you want for which class period
JA Economics, JA Be Entrepreneurial, JA Careers with a Purpose, JA Global Marketplace, JA Company Program, JA America Works, JA Titan, JA It's My Business!, JA Success Skills, JA Economics for Success, JA Business Ethics, JA Job Shadow, JA Exploring Economics, JA Personal Finance

Class Time

Day

# of Students

To Request previous Years Volunteer

Please specify fall or spring semester

M: T:
W: TH: F

F: S

M: T:
W: TH: F
F: S

M: T:
W: Th: F
F: S

M: T:
W: Th: F
F: S

M: T:
W: Th: F
F: S

M: T:
W: Th: F
F: S

M: T:
W: Th: F
F: S

M: T:
W: Th: F
F: S

Volunteer Referral: Do you know someone who has never volunteered for JA who would enjoy to volunteer?

Name: Phone #:

Teacher Agreement:

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 am committing to contact my volunteer immediately to arrange a schedule suitable for their work schedule and my classroom schedule. The program consists of 6 - 8 visits to the classroom about 40-50 minutes. I accept the responsibility to remain in the classroom with my Junior Achievement volunteer at all times. I understand that JA has committed funding for the curriculum and the completion of this JA class. If I am unable to complete my commitment to the program I will notify the Junior Achievement office immediately!!

I agree to these terms: I Agree: I Disagree

Junior Achievement Privacy Policy

PLEASE Specify below which program(s) you want for which class period JA Economics, JA Be Entrepreneurial, JA Careers with a Purpose, JA Global Marketplace, JA Company Program, JA America Works, JA Titan, JA It's My Business!, JA Success Skills, JA Economics for Success, JA Business Ethics, JA Job Shadow, JA Exploring Economics, JA Personal Finance	Class Time	Day	# of Students	To Request previous Years Volunteer	Please specify fall or spring semester
		M: T: W: TH: F			F: S
		M: T: W: TH: F			F: S
		M: T: W: Th: F			F: S
		M: T: W: Th: F			F: S
		M: T: W: Th: F			F: S
		M: T: W: Th: F			F: S
		M: T: W: Th: F			F: S
		M: T: W: Th: F			F: S