Home Wine-Making Workshop (Paragould)
Please complete this form to begin your registration for the Home Wine-Making Workshop. 

Registration is not complete until payment of $85 is received in full.  Checks may be mailed to Black River Technical College, Community Education, P.O. Box 468, Pocahontas, AR. 72455.  

Payments may also be submitted by phone at 870-248-4180.   (A 3% fee will be applied to all credit card payments resulting in a charge of $87.55) 

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Email *
First Name *
Middle Name *
Last Name *
Mailing Address  
(Example: 1234 Test Way)
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City, State, and Zip Code 
(Example: Pocahontas, AR 72455)
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Date of Birth *
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Sex: *
Phone Number (Ex: (555-555-5555) *
Email Address *
What Type Would You Like to Make? *
How did you hear about this class? *
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