Thank you for registering with Junior Achievement for your class. Please register all classes on the same form. We look forward to working with you to make this year the best ever!
JA Class Registration Form 2018-19
County:
*
Hernando
Hillsborough
Manatee
Pasco
Pinellas
Sarasota
Polk
Highlands
Alachua
Citrus
Marion
School Name:
*
School Phone Number
-
Area Code
Phone Number
School Start Time
Will Proposed Date Work?
*
Yes
No, New Date Needed
Week-to-Week Class
Full Name:
*
Prefix
First Name
Last Name
Title (ex. Team Leader)
*
Team Leader Cell Number
-
Area Code
Phone Number
E-mail:
*
Grade
*
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Mixed Elementary
Mixed Middle
Mixed High
Gender:
*
Male
Female
Ethnicity:
*
Caucasian
African-American
Hispanic
American Indian
Hawaiian/Polynesian
Asian
Multi-Racial
Other
Prefer not to answer
Is there anything we should know about the class(es)? (class times, specials, etc)
Class Information
Teacher Name - 1
*
Prefix
First Name
Last Name
Ethnicity
*
African American
Caucasian
Hispanic
Asian/Pacific Islander
American Indian
Multi
I prefer to not answer
This information is used for grant purposes only.
Gender:
*
Male
Female
Class Type
*
Gifted
Regular
Other - Please Specify In Comment Box Below
If you choose other above, pleae specify
Lunch Time Starts
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
# of Students
*
If you have more classes,click NEXT. If you are finished, please click SUBMIT.
Submit Form
Back
Next
*If teacher information is the same, you may leave it blank and skip directly to grade.
Teacher Name - 2
*
Prefix
First Name
Last Name
Ethnicity
*
African American
Caucasian
Hispanic
Asian/Pacific Islander
American Indian
Multi
I prefer to not answer
This information is used for grant purposes only.
Gender:
*
Male
Female
Class Type
*
Gifted
Regular
ASD
Other - Please Specify In Comment Box Below
If you choose other above, pleae specify
Lunch Time Starts
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
# of Students:
*
If you have more classes,click NEXT. If you are finished, please click SUBMIT.
Submit Form
Back
Next
*If teacher information is the same, you may leave it blank and skip directly to grade.
Teacher Name - 3
*
Prefix
First Name
Last Name
Ethnicity
*
African American
Caucasian
Hispanic
Asian/Pacific Islander
American Indian
Multi
I prefer to not answer
This information is used for grant purposes only.
Gender:
*
Male
Female
Class Type
*
Gifted
Regular
ASD
Other - Please Specify In Comment Box Below
If you choose other above, pleae specify
Lunch Time Starts
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
# of Students:
*
If you have more classes,click NEXT. If you are finished, please click SUBMIT.
Submit Form
Back
Next
*If teacher information is the same, you may leave it blank and skip directly to grade.
Teacher Name - 4
*
Prefix
First Name
Last Name
Ethnicity
*
African American
Caucasian
Hispanic
Asian/Pacific Islander
American Indian
Multi
I prefer to not answer
This information is used for grant purposes only.
Gender:
*
Male
Female
Class Type
*
Gifted
Regular
Other - Please Specify In Comment Box Below
If you choose other above, pleae specify
Lunch Time Starts
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
# of Students:
*
If you have more classes,click NEXT. If you are finished, please click SUBMIT.
Submit Form
Back
Next
*If teacher information is the same, you may leave it blank and skip directly to grade.
Teacher Name - 5
*
Prefix
First Name
Last Name
Ethnicity
*
African American
Caucasian
Hispanic
Asian/Pacific Islander
American Indian
Multi
I prefer to not answer
This information is used for grant purposes only.
Gender:
*
Male
Female
Class Type
*
Gifted
Regular
Other - Please Specify In Comment Box Below
If you choose other above, pleae specify
Lunch Time Starts
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
# of Students:
*
If you have more classes,click NEXT. If you are finished, please click SUBMIT.
Submit Form
Back
Next
*If teacher information is the same, you may leave it blank and skip directly to grade.
Teacher Name - 6
*
Prefix
First Name
Last Name
Ethnicity
*
African American
Caucasian
Hispanic
Asian/Pacific Islander
American Indian
Multi
I prefer to not answer
This information is used for grant purposes only.
Gender:
*
Male
Female
Class Type
*
Gifted
Regular
Other - Please Specify In Comment Box Below
If you choose other above, pleae specify
Lunch Time Starts
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
# of Students:
*
If you have more classes,click NEXT. If you are finished, please click SUBMIT.
Submit Form
Back
Next
*If teacher information is the same, you may leave it blank and skip directly to grade.
Teacher Name - 7
*
Prefix
First Name
Last Name
Ethnicity
*
African American
Caucasian
Hispanic
Asian/Pacific Islander
American Indian
Multi
I prefer to not answer
This information is used for grant purposes only.
Gender:
*
Male
Female
Class Type
*
Gifted
Regular
Other - Please Specify In Comment Box Below
If you choose other above, pleae specify
Lunch Time Starts
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
# of Students:
*
If you have more classes,click NEXT. If you are finished, please click SUBMIT.
Submit Form
Back
Next
*If teacher information is the same, you may leave it blank and skip directly to grade.
Teacher Name - 8
*
Prefix
First Name
Last Name
Ethnicity
*
African American
Caucasian
Hispanic
Asian/Pacific Islander
American Indian
Multi
I prefer to not answer
This information is used for grant purposes only.
Gender:
*
Male
Female
Class Type
*
Gifted
Regular
Other - Please Specify In Comment Box Below
If you choose other above, pleae specify
Lunch Time Starts
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
# of Students:
*
If you have more classes,click NEXT. If you are finished, please click SUBMIT.
Submit Form
Back
Next
*If teacher information is the same, you may leave it blank and skip directly to grade.
Teacher Name - 9
*
Prefix
First Name
Last Name
Ethnicity
*
African American
Caucasian
Hispanic
Asian/Pacific Islander
American Indian
Multi
I prefer to not answer
This information is used for grant purposes only.
Gender:
*
Male
Female
Class Type
*
Gifted
Regular
Other - Please Specify In Comment Box Below
If you choose other above, pleae specify
Lunch Time Starts
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
# of Students:
*
If you have more classes,click NEXT. If you are finished, please click SUBMIT.
Submit Form
Back
Next
*If teacher information is the same, you may leave it blank and skip directly to grade.
Teacher Name - 10
*
Prefix
First Name
Last Name
Ethnicity
*
African American
Caucasian
Hispanic
Asian/Pacific Islander
American Indian
Multi
I prefer to not answer
This information is used for grant purposes only.
Gender:
*
Male
Female
Class Type
*
Gifted
Regular
Other - Please Specify In Comment Box Below
If you choose other above, pleae specify
Lunch Time Starts
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
# of Students:
*
If you have more classes,click NEXT. If you are finished, please click SUBMIT.
Submit Form
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