12th Annual WWU Children’s Literature Conference Saturday, February 28, 2015 Please complete a separate registration form for each participant (For groups of three or more use group registration form) Visit the WWU CLC website for conference details and information: www.wwuclc.com Name: Please print (Last, First, M.) Day Phone: WWU Student Number: (if available) Date of Birth: (M/D/Y) Mailing Address: ☐ Home | ☐ Work E-Mail: Please print legibly City: State: Zip: School/Work Affiliation: Special Needs/Accommodations: WWU CLC Registration Registration Item √ Early Bird Registration* Late Rate Payment* (By 1/15/15) (After 1/15/15) Amount ☐ Conference Registration $95.00 $125.00 $ ☐ Para-Educator, Retired Teacher or WWU Employee Registration $40.00 $50.00 $ ☐ Full-Time College Student Registration $30.00 $40.00 $ ☐ Student Volunteer (by permission only) $15.00 $15.00 $ ☐ I would like to donate to student registrations in the amount of $5, $10, or $20: $ Total Amount for Registration (and Donation) Fees: $ *Note: For Early Bird registrations, the form must be received by 1/15/15; forms received with a later postmark date will be returned. Clock Hours will be available on-site at the conference. Please remember to bring your WA State Certificate #. CANCELLATION / NO SHOWS: No refunds for registrations. This policy applies to all registrations, including those forms accompanied by an institutional purchase order. Substitutions will be accepted until 2/26/15. For Registration/Payment Information: For Program Information: Extended Education Nancy Johnson, English Department e-Mail: ExtendedEducation@wwu.edu e-Mail: Nancy.Johnson@wwu.edu Phone: (360) 650-3308 Phone: (360) 650-3227 By signing this line, I agree to the cancellation policy above and that the information I provided on this registration form is accurate: X __________________________________________________________________________________ Signature For Office Use Only: ____________________ Date ☐ Receipt via E-Mail/USPS ☐ Enter in Cosmos C 1 INDEX ACCT ACTV FXCON G504 CSHCEZ Note to SB0: Return form to ExtEd, MS 9102 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PAYMENT INFORMATION (U.S. Funds Only) ► Payment must be included at time of registration. WWU/Extended Ed. will send you an e-receipt and confirmation of registration upon receipt of completed registration form with payment. Mail Registration & Payment to: WWU Cashier – Extended Ed 516 High Street, MS 9004 Bellingham, WA 98225 ☐ Institutional PO #: _____________________________ (Include a copy of the PO) ☐ Check/Money Order payable to WWU ☐ Visa ☐ MasterCard ☐ AmEx ☐ Discover Expiration Date: ______________ Secure FAX: (360) 788-0854 (registrations with credit card payments only) Card Number: _______________________________________________________________ Signature: __________________________________________________________________