Parent/Provider Payment Request Form

Parent/Provider Payment Request Form

Reimbursement will only be allowed up to 10 days after an event.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
Phone Number*
Which options are you requesting reimbursement for?*

AttendanceMileageChild Care

Attendance
Attendance Info:

Time Reimbursement is $20/hour.
Name of Meeting/Training/Activity Attended:

Coalition MeetingFocus GroupOther
Date Attended:

MonthDayYear
Date
Meeting Start Time:

Hour Minutes

AM/PM Option
Meeting End Time:

Hour Minutes

AM/PM Option
Tasks Completed for this Meeting/Training/Activity (check all that apply):

AttendanceSurveyFocus GroupInterviewOther - Assigned Task
Please Describe Task(s):
Total Prep Time (In Minutes):
Total Travel Time (In Minutes):
Total Activity Time (In Minutes):
Total Combined Time (In Minutes):
Attendance Time Reimbursement Amount

Mileage
Mileage

Record only travel associated with meeting or activity participation listed above.
Total Mileage
Total Mileage Reimbursement ($) (rate of $0.655)

Child Care
Child Care:

Child Care Reimbursement is $10 or $13 per hour, up to $60 per child per day. Please attached signed child care form.
Provider Name:
Date of Care:

MonthDayYear
Date
Child care services provided

StandardSpecial Needs
Number of Children in Child Care:
Total Number of Minutes of Care Provided:
Total Child Care Reimbursement Amount

Reimbursement Summary and Attachments
Expense Request:

Totals will auto-populate from above sections.
Time Reimbursement
Mileage Reimbursement
Child Care Reimbursement
Total Reimbursement Amount
I AM REQUESTING REIMBURSEMENT FOR THE EXPENSES LISTED ABOVE. (Required)*

Clear
Date*

MonthDayYear
Date
Documents

Please attach all supporting receipts, mileage justifications and other supporting documents for expenses.
Please attached all travel documents

Cancelof
Please attach child care documents

Cancelof
Should be Empty:

Attendance Info: