Request Form

Elementary Class Request Form

Teacher:               School Address: 

 Home Address:                   Home #: 

School #:                                              Subject/grade level: 

School Fax #:                  School: 

Planning Period:           E-mail: 

To help JA comply with donor and grant requirements please provide teacher information:
Gender: Male: Female
Age: Under 25: 25-35: 36-50: over 50
Ethnicity:: Asian: American Indian: African American: Caucasian: Hispanic: Alaskan Indian

One form per Teacher  Which Semester? Fall or Spring

Number of Classes	JA Program	Number of Students	Other information	To Request Previous Years Volunteer
	Kindergarten (Ourselves) Please note am, pm or all day
	1st grade (Our Families)
	2nd grade (Our Community)
	3rd grade (Our City)
	4th grade (Our Region)
	5th grade (Our Nation)

Volunteer Referral:  Do you know someone who has never volunteered for Junior Achievement that would enjoy volunteering?

Name:      Phone #: 

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 a contact my volunteer immediately to arrange a schedule suitable for their work schedule and my classroom schedule.  The program consists of 5 visits to the classroom about 30-45 minutes to be completed this semester.  I accept the responsibility to remain in the classroom with my Junior Achievement volunteer at all times.  I understand that Junior Achievement has committed funding for this class and if I am unable to complete my committment to the program I will notify the Junior Achievement office immediately!

I agree to these terms: I  Agree: I  Disagree

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