Name *

First Name

Last Name

Phone

(###)

###

####

Teacher's Name *

First Name

Last Name

Grade(s) Taught *

Select more than one, if applicable.

6th Grade

7th Grade

8th Grade

9th Grade

10th Grade

11th Grade

12th Grade

Date of Completion *

MM

DD

YYYY

Did you complete the full program? *

Yes

No

To what degree do you agree with the following? *

I felt well trained and supported by the JA staff.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

My teacher was cooperative and communicated well in arranging my JA visits.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

My teacher remained in the classroom and provided discipline when appropriate.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

If yes, would you like to work with the same teacher?

Yes

No

May we share your story/quote?

Yes

No

Name

First Name

Last Name