Freewrite Workshop Registration "*" indicates required fields Name* First Last Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email* PhoneHow did you hear about this workshop? Please choose the workshop you'd like to register for:*Thursday, Jun 8, 2023, 11am-12:30pm PTTuesday, Jun 27, 2023, 4-5:30pm PTThursday, Jul 13, 2023, 11am-12:30pm PTTuesday, Jul 25, 2023, 4-5:30pm PTThursday, Aug 10, 2023, 11am-12:30pm PTTuesday, Aug 22, 2023, 4-5:30pm PTThursday, Sep 14, 2023, 11am-12:30pm PTTuesday, Sep 26, 2023, 4-5:30pm PTSliding scale fee $5-$50*Your workshop fee directly supports our free writing workshops in low-income housing communities, correctional facilities, hospitals, schools, treatment centers and other social service agencies. Total Credit/Debit Card Information American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Expiration Month010203040506070809101112 Year Expiration Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Security Code Cardholder Name * I have read and agree to the Registration, Cancellation, and Refund Policy. HiddenHave you been previously or currently involved with us? Check all that apply: Volunteer Donor Partner Prompt/HOTLIPS Pizza writing workshop participant Writing Workshop participant I’m new to you! Other HiddenConfirmation I confirm that I am over 18 years of age (if under 18, do not submit this form; contact our Program Director at firstname.lastname@example.org or call 503-796-9224).