Class Registration


County:
School: *
Teacher First Name: *
Teacher Last Name *
Program Requested:
School Phone:
Fax:
E-mail: *
Preferred method of contact:
Preferred Month
Lunch Time:
Room #:
Regular Ed? / Other?
# of Students *
Teacher's Gender *
Teacher's Ethnic Origin:
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:
Email Address:
Name:
Phone Number:
Email Address:
Additional Comments?