GRASSROOTS RADIO CONFERENCE 11
July 27-30, 2006  |  Madison, WI

-- REGISTRATION FORM --

Name: _________________________________________________

Street address: _________________________________________________

City/State/Zip: ______________________________________________

Phone:_____________________________ Email: ___________________________

Organization name: _________________________________________

Planning to attend: __ All days  __ Thursday  __ Friday  __ Saturday  __ Sunday

Time/day of arrival: ____________________  Time/day of departure: ____________________

__ Will pay full conference rate ($80)

__ Need scholarship, but can pay $______

Dietary needs: _________________________________________________________

Allergies or other special needs: _____________________________________

_______________________________________________________________________

I want to learn:




I want to teach:




Please return this registration form with payment (by check) to:
WORT-FM
c/o GRC-11 Registration
118 S. Bedford St.
Madison, WI  53703

Visit http://GrassrootsRadio.info for housing and transportation information, (including low/no-cost options) and the conference workshop schedule when it becomes available.