Info Hear-N-Now Registration Registration for the 19th Annual CCCDP and NC AG Bell "Hear-N-Now Conference" November 8th and 9th, 2012 First Name Last Name Title Your E-Mail Address I give my permission to share my email address with other attendees. Address City State Zip Phone Number Fax Number County Employer Charges Registration without lodging - $175 ($20 non-refundable) Registration with lodging for Thursday only (4 meals) - $230 Registration with lodging for Wednesday and Thursday (5 meals) - $270 Private room - Additional $60 Total Charges Add together all of the charges selected above and enter the amount here: Discounts Early Bird Registration (Payment postmarked before Oct. 26, 2012) - $30 off Parent - $30 off Student - $30 off Please send a copy of your University ID with payment. AG Bell Member - $20 off Information on joining AG Bell can be found at www.ncagbell.org Total Discounts Add up the total of the discounts selected above and enter it here: Total Amount Due Subtract the total discounts for the total charges and enter the amount here: Name of Roommate If left blank and "private room" is not selected, a roommate will be assigned for you. Supportive Services Registration materials must be received by the deadline to ensure availability of listed services. I need an assistive listening device. I need a sign language interpreter. I need a cued speech transliterator. Comments I have read and understand the registration guidelines • There is a $20 non-refundable registration fee • Registration deadline is Friday November 2nd 2012. Registrations received after this date will be processed on a first come first served basis with no guarantee of acceptance for attendance • Upon registration, if you entered a valid e-mail address, you will receive a confirmation e-mail. Please print the registration email or the following confirmation of registration and mail a copy with your payment. Registration is not considered complete until payment has been received. • Check should be made out to CASTLE and payment must be mailed to: CASTLE Attn: Robert Humphreys 5501 Fortunes Ridge Dr., Suite A Durham, NC 27713 • Contact Robert Humphreys with questions at email@example.com or 919-419-1428.