Name:

Age:

Address:

Email Address:

Home Phone:

Cell:

Name of Parent or Guardian (please indicate which):

Parent/Guardian contacts (if different from above): Previous Video Experience (none required):

Video Interests:

What workshop are you registering for?

Which session (June or July)?

Workshop Fee for materials:

Registration fee is due prior to the first session. It may be paid on- line or a check, payable to WIN-TV Workshop, is acceptable.