County:
School:
*
Teacher First Name:
*
Teacher Last Name
*
Program Requested:
School Phone:
Fax:
E-mail:
*
Preferred method of contact:
School Phone
E-mail
Preferred Month:
Sept-Nov
Oct-Dec
Jan-March
Feb-April
Lunch Time:
Room #:
Regular Ed? / Other?
# of Students
*
Teacher's Gender
*
Maie
Female
Teacher's Ethnic Origin:
African-American
Alaskan Native
American Indian
Asian
Caucasian
Hawaiin
Hispanic
Multi-Racial
Other
Demographic information collected by JA is used for statistical purposes only. It is not used for individuals, but used only in aggregate form. JA is a non-profit organization that applies for grants and funding from various entities. In these applications, we need to provide statistical information to demonstrate that JA reflects the diversity of the communities we serve. We appreciate your assistance in ensuring JA’s continued service to our children.
Please provide names of individuals who would be interested in teaching JA to your class.
Name:
Phone Number:
Name:
Phone Number:
Additional Comments?
Submit
Should be Empty: