Teacher or Administrator Data/Contact Form
Teacher Name:
*
School:
*
Address
City/Town:
*
School Phone:
*
School Fax:
Classroom Phone:
Cell Phone:
Grade/Program You Teach
Home Phone:
Email address:
*
Due to requirements for certain grants and funding, we need the following information:
Your Gender:
*
Male
Female
Your Ethnicity:
*
African American
Alaskan Native
American Indian
Asian
Caucasian
Hispanic
Hawaiian
Multi-Racial
Info Not Provided
Have you had JA in your classroom in CT since 2003?
Yes
No