Hear-N-Now Registration

First Name (Required)

Last Name (Required)

Title

Your E-Mail Address (Required)

Address (Required)

City (Required)

State (Required)

Zip (Required)

Phone Number (Required)

Fax Number

County (Required)

Employer

Charges

Registration without lodging - $175

Registration with lodging for Thursday only (4 meals) - $220

Registration with lodging for Wednesday and Thursday (5 meals) - $260

Private room - Additional $50

Total Charges (Required)

Add together all of the charges selected above and enter the amount here:

Discounts

Early Bird Registration (Payment postmarked before Oct. 14, 2011) - $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 (Required)

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 (Required)

• There is a $20 non-refundable registration fee • Registration deadline is Friday October 28th, 2011. 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 rhumphre@unch.unc.edu or 919-419-1428.

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