Student Name*

	Name of Person Submitting Shout Out*

	Grade Level*
	--Please Select--KindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth Grade

	Homeroom Teacher Name*

	Message:* Write out your message the way the Message will be announced on the morning news. Follow a letter writing format.

	Date to Air the Shout Out* Notifications must be made 2 days prior to request to have Shout Out aired.
	mm/dd/yyyy

	Print a copy of this Form and Submit your $5 fee for the Shout Out prior to the date to air the Shout Out. Thank you for your support of the Media Department at WPE.