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Childcare Funding Request
Request for reimbursement for civic engagement
Please submit the following information so we can determine if your request can be funded. Politisit reserves the right to determine whether or not to fund this request based on our mission, priorities, and available resources. Please provide as much information as possible so it can be properly evaluated. We will evaluate the request as quickly as possible, so please understand requesting at least 72 hours in advance is appreciated. Politisit pays for care at the caregiver’s local market rate. Should Politisit fund your request, Politisit reserves the right to check that the event was attended as outlined in the request. Please note that you need to apply to be part of the program before making a funding request here.
Name
*
First Name
Last Name
Email
*
example@example.com
Name of Event
*
Organization coordinating or holding the event
*
If not applicable, N/A is fine
Date of Event
*
-
Month
-
Day
Year
Date
Total Time of Event
*
(total hours, start to finish)
Location of Event
*
Purpose of Event
*
Total Estimated Cost for Childcare
*
Enter dollar amount
Name of Childcare Provider
First Name
Last Name
Is this event a part of a job, internship/school, campaign/elected position, or other form of employment?
*
Yes
No
Please provide any further information you would like Politisit to consider about your request.
Declaration
You declare under penalty of perjury that all the information provided on this form is true and correct to the best of your knowledge, and that you are using the child care funds requested only for the purpose of attending the event or activity you have listed. You understand that anyone who knowingly gives a false or misleading statement in this electronic form, or causes someone else to do so, commits a crime and may be subject to penalties under Federal and/or state law. By signing, I declare that everything in this form is true to the best of my knowledge.
Signature
*
If you are applying on behalf of an organization, please add your title here:
If you are applying on behalf of an organization, how much of the total cost of childcare will you need Politisit to reimburse?
Enter dollar amount
Submit
Should be Empty: