The City of Winchester’s INSIGHT Citizen’s Academy is a unique opportunity for residents to learn about their local
government in order to foster a better understanding and working relationship between the two. If you are unable to pay
the program fee and would like to participate, please indicate below. This information will be kept confidential and will
only be viewed by the Academy Coordinator (City’s Communications Director).
Full Name _______________________________________________________________ Shirt Size: _______________
Mailing Address __________________________________________________________ Zip _____________________
Day Phone ______________________ Email ____________________________________________________________
Are you planning to attend all sessions? Yes No If no, please explain.
__________________________________________________________________________________________________
Note: In order to gain a complete understanding of the big picture, it is highly recommended that you attend all sessions.
How would you rate your current knowledge of the
City of Winchester’s services, operations and procedures?
How did you hear about INSIGHT?
_______________________________________
1 2 3 4 5
Very Low Low Average High Very High
Please explain. _____________________________________________________________________________________
__________________________________________________________________________________________________
List any food allergies or special accommodations you may need during the program:
__________________________________________________________________________________________________
“I hereby give my permission for the City of Winchester to use any still photograph or video in which I may appear for
whatever purpose(s) deemed appropriate. I participate in this program voluntarily and with the understanding there is no
remuneration and a fee to participate. I also understand that I may request the fee be waived if I cannot pay.”
Signature __________________________________________________________ Date _________________
Please return to: Amy Simmons
Communications Director
City of Winchester
15 North Cameron Street, Winchester, VA 22601
(540) 667-1815, ext. 1670 | (540) 722-3409
NOTES:
• Registration forms are accepted rst-come, rst-served.
• The program will be canceled if the minimum participation
requirement is not met.
Program Fee: $25 per person
Fee helps cover the cost of
transportation
and supplies.
Make checks payable to:
City of Winchester
Fee waiver request (please initial) _________
City of Winchester’s INSIGHT Citizen’s Academy
2020 Registration Form
click to sign
signature
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