Name:

Address:

City:

State:

Zip:

Phone:

Email:

Personal Web Page:

Session:

List any training or experience you have as a journalist::

Do you have specific ideas about how you want to make use of this training?:

What communities are you likely to do stories for?:

What is your level of knowledge and experience with web and other technologies? Do you have any specific skills that you could use to create stories including photographs, video or audio?: