Teacher Class Request

Are you a teacher who would like to request a JA Program in your classroom?  Please complete the form below one time per program/class period requested and a JA staff member will contact you when a volunteer has been matched with your class.  If you have any questions, please contact Ron Wigglesworth, Program Manager (ron@jalexington.org or 859/219-2423). Click here for program descriptions. 

Teacher Information

Title                                       

First Name                          

Middle Initial                       

Last Name                            

Email Address                      

Work Phone                          

Work Fax                              

Home Address:                     

City:                                       

Zip:                                         

Home Email:                         

Home Phone                        

Planning Time                      

Best way to reach me at school: 

For funding and grant information only, please complete the following.  (Information will not be shared on an individual basis.)

Gender:   Ethnicity: 

Volunteer Information (Please add phone/email if known)

Volunteer Requested             

Volunteer Work Phone:       

Volunteer Home Phone:     

Volunteer Email:                   

Has agreed to teach your class? Yes   No

Class Information

School                                   

Grade Being Taught           

Elementary Program Requested: 

Middle School Program Requested: 

High School Program Requested: 

Semester Preference            

Time Preference                    Month Preference: 

Number of Students            

Have you ever hosted a JA class before?  Yes    No
(First time teachers will need to meet with JA Staff)