GROUP (3+ People) REGISTRATION ONLY 11th Annual WWU Children’s Literature Conference Saturday, February 28, 2015 Please complete a separate registration form for each participant 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 Group Registration ONLY! √ Registration Item Group Registration* ☐ Conference GROUP Registration $85.00 per person ☐ I would like to donate to student registrations in the amount of $5, $10, or $20: (By 1/15/15) Amount $ $ Total Amount for Registration (and Donation) Fees: $ *Note: For all Group Registrations, the form must be received by 1/15/15; forms received with a later postmark date will be returned. All registrations must be submitted together in a group of three or more to be eligible for the Group Registration rate. 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 9102 Bellingham, WA 98225 Secure FAX: (360) 788-0854 (registrations with credit card payments only) ☐ Institutional PO #: _____________________________ (Include a copy of the PO) ☐ Check/Money Order payable to WWU ☐ Visa ☐ MasterCard ☐ AmEx ☐ Discover Expiration Date: ______________ Card Number: _______________________________________________________________ Signature: __________________________________________________________________