Today's Date *

MM

DD

YYYY

Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

To receive a discounted fee check all that apply (discounts can be 100% depending on need and qualification)

I live/farm in Bullock County

I work for or with an Ag Extension

I am an agriculture instructor

I teach agriculture or electrical engineering at a tech education center

I teach at a Community College/ University

I am an agriculture, electrical engineering, or environmental engineering student

I am a presenter at the Institute

I work with a community organization

I work with a community farmers market

I plan to volunteer at Little USA in Union Springs

Do you have internet access (Broadband, Wifi, Internet)? *

Yes

No

Prior to the 1st day of the workshop, will you be able to complete the required online course? *

Yes

No

Prior to the 1st day of the workshop, will you be able to read required chapters form the textbook provided? *

Yes

No