Childcare Reimbursement
Parent Name:
*
First Name
Last Name
Email
*
example@example.com
Please note in-person session(s) you attended.
*
Please include date and title of session, i.e. (6/20-Returning Parent Orientation).
Please note in-person session(s) you attended. Select each session attended.
*
Other - Coordinators ONLY
New Family Kick Off - June 25th
Returning Family Kick Off - July 2nd
Returning Family Kick Off (#2) - July 30th
New Family Kick Off (#2) - July 31st
Mandatory Parent/Student Conferences - Aug. 5th
Mandatory Homeschool - Aug 8th
Mandatory All Family - Aug 15th
Please type in name and date of session if you could not select more than one option above.
Total number of children
12
and under:
Children
*
Children
*
.
Childcare Reimbursement
*
1-2 Children - $25.00
3-4 Children - $45.00
5 or more Children - $65.00
Do you prefer an Electronic Payment or Paper Check?
*
Electronic Payment
Paper Check
Provide Address for Check
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Copy of a Receipt or Document from Provider (even if older sibling)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: