Educator Registration

Program Registration Form for Educators

Note: fields marked with * are required

Select Local JA:: *

Please choose your Local JA charter [if different from the current one]

Region:

First name: *

Please enter your first name

Last name: *

Please enter your last name

Title:

Email: *

Please specify your email address

Daytime phone number: *

Fax number:

Secondary contact information:

First name:

Last name:

Title:

Email:

Phone number:

School and program information:

School: *

School District / School Board No.:

School Address: *

City: *

Postal Code:

Teacher Home/Cell number:

Grade level:

Class size:

Preferred time to participate:

I have participated in this program before:

If 'yes' - last year I participated:

Additional notes:

By submitting this Program Registration Form, I understand and agree to the responsibilities of hosting JA program.

These responsibilities are:

To communicate with JA Office Staff and JA Volunteer(s) in a timely manner;
To contact the JA office immediately if I cannot fulfill my registration obligations due to unforeseen circumstances;
To communicate the responsibilities to all teachers at my school who will be hosting a JA program in their class;
To ensure all participating teachers complete a registration form;
To attend a JA orientation prior to hosting a JA program if I have not participated in the program before

I Agree: *

Type in 'Yes' to sign this form - thank you.