You Pick, We Pay Childcare Reimbursement

At Prairie Lakes Church, we want to make it simple for you to participate in church events without worrying about babysitting expenses. With You Pick, We Pay, you pick and pay your babysitter. Then, submit a You Pick, We Pay form to be reimbursed for a portion of your babysitting expenses. With this form, you can submit up to five requests for reimbursements.
Which campus do you most often attend?*
Make Reimbursement Payable To
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
Phone Number*

Area CodePhone Number
Reimbursement Request 1
Date of event you're requesting reimbursement for*

MonthDayYear
*Forms must be turned in within 4 weeks of the event date.
Event*
Number of Children*
Hours*
Reimbursement rates are as follows:

1 Child: $4/hour
2 Children: $5/hour
3 Children: $6/hour
4 Children: $7/hour
5+ Children: $8/hour

Please note that groups of 5 or more children will be reimbursed at a maximum rate of $8/hour.

Reimbursement Request 2
Additional date of event you're requesting reimbursement for*

MonthDayYear
Date
Additional date of event you're requesting reimbursement for

MonthDayYear
Event*
Number of Children*
Hours*
Reimbursement rates are as follows:

1 Child: $4/hour
2 Children: $5/hour
3 Children: $6/hour
4 Children: $7/hour
5+ Children: $8/hour

Please note that groups of 5 or more children will be reimbursed at a maximum rate of $8/hour.

Reimbursement Request 3
Additional date of event you're requesting reimbursement for*

MonthDayYear
Date
Event*
Number of Children*
Hours*
Reimbursement rates are as follows:

1 Child: $4/hour
2 Children: $5/hour
3 Children: $6/hour
4 Children: $7/hour
5+ Children: $8/hour

Please note that groups of 5 or more children will be reimbursed at a maximum rate of $8/hour.

Reimbursement Request 4
Additional date of event you're requesting reimbursement for*

MonthDayYear
Date
Event*
Number of Children*
Hours*
Reimbursement rates are as follows:

1 Child: $4/hour
2 Children: $5/hour
3 Children: $6/hour
4 Children: $7/hour
5+ Children: $8/hour

Please note that groups of 5 or more children will be reimbursed at a maximum rate of $8/hour.

Reimbursement Request 5
Additional date of event you're requesting reimbursement for*

MonthDayYear
Date
Event*
Number of Children*
Hours*
Reimbursement rates are as follows:

1 Child: $4/hour
2 Children: $5/hour
3 Children: $6/hour
4 Children: $7/hour
5+ Children: $8/hour

Please note that groups of 5 or more children will be reimbursed at a maximum rate of $8/hour.
Should be Empty:

Make Reimbursement Payable To