12 Annual WWU Children’s Literature Conference

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: [email protected]
e-Mail: [email protected]
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: __________________________________________________________________