Middle & High School Program Request Form

If you are interested in having a JA program in your classroom in the FALL or SPRING semester, please carefully fill out the following information as completely as possible and fax/return it, so that we can recruit and train consultants/volunteers.

We will contact you shortly so that you can give us your class schedules and we can match up volunteers. Classes will be offered on a first come first serve basis. Please notice that our menu of programs has been changed for the new school year.

Teacher Name* required

Home Phone

Cell Phone

Email* required

Home Email

*Some schools block email from Junior Achievement and we may have important information regarding JA that we need to get to you

School Name* required

District* required


School Phone* required

Work Direct Phone

Preferred Contact Method

Gender (required for grants & funding)* required

Ethnicity (required for grants & funding)* required

Number of Students

Grade (Middle/High)

JA Program (Middle/High)

Course Title


Class Start Time

Class End Time

Semester (text)

Full Year Class?

Other Important Class Information?

For additional classes, please provide the following:

Have you had a JA consultant in your classroom before?

Would you like any previous volunteers to return?

please fill out as completely as possible

Please add any additional comments