Middle School Request Form

You can submit your request below or download a PDF of the form here to print, scan, email, or submit via fax or to (401) 351-9860. We invite you to view current programs and overviews.

Please carefully read through the delivery requirements before submitting a request for programming.

JA Inspire 2022-2023 registration forms for eighth-grade classes only will be available soon. All other middle school level classes may be requested below.

If you have any questions, please contact Sara Hutchings-Schwartz at sara.schwartz@ja.org.

Contact Name

First Name

Last Name

Contact Phone-Direct

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Contact Email Address

School Name

School Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

School Phone Number

(###)

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Principal Name

First Name

Last Name

Principal Email

Are you able to provide computers and internet access?

Have you requested JA programs before?

Teacher 1

First Name

Last Name

Teacher 1 Email

Teacher Direct Line

(###)

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Requested Program Name 1

Grade Level

Accomodations

Please code as follows for any needed accommodations: ESL (Spanish Material Requested), ELL (Multi-lingual Room), IEP/504 (Most/Whole Class), B/SC (Behavioral/ Self Contained Room), OA (Other Accommodations)

Number of Classes/Periods

Total Number of Students

Semester

Fall (August-December)

Spring (January-June)

Summer Programming

Target Start and End Dates

Teacher 2 Name

First Name

Last Name

Teacher 2 Email

Teacher 2 Direct Line

(###)

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Requested Program Name 2

Grade Level

Accomodations

Number of Classes/Periods

Total Number of Students

Semester

Fall (August-December)

Spring (January-June)

Summer Programming

Target Start and End Dates

Teacher 3 Name

First Name

Last Name

Teacher 3 Email

Teacher 3 Direct Line

(###)

###

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Grade Level

Accomodations

Requested Program Name 3

Number of Classes/Periods

Total Number of Students

Semester

Fall (August-December)

Spring (January-June)

Summer Programming

Target Start and End Dates

By clicking submit you are agreeing to all the delivery requirements found on this page. Please carefully read through them before submitting a request for programming.