Adaptive Coach Travel/Education Reimbursement Application

Adaptive Coach Travel/Education Reimbursement Application

Application for club reimbursement of coach travel expenses for select Meets/Event/Clinic. This form is to be used in conjunction with NI P&P Questions, contact disability@niagaraswim.org
Contact Information

Please provide contact information for the person making the request.
Club Name*
Name*

First NameLast Name
Title*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Meet/Event/Clinic Information
Name of the Meet/Event/Clinic*
Address of Meet/Event/Clinic- if virtual provide home address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Meet/Event Start Date*

MonthDayYear
Date
Governing Body Sponsoring Meet/Event/Clinic*
Did you receive prior approval from the Disability Committee?*

YesNo
Please provide the link to the Meet/Event/Clinic information page*
Attendee Information
Name of Attendee*

First NameLast Name
USA Swimming Member ID*
Reimbursement Request

Up to $500 per Niagara Calendar year.
Amount*
Can include: travel expenses (mileages, housing, transportation, etc.) cost of Meet/Event/Clinic
Please provide one (1) PDF with all receipts. If you have more than one (1) PDF please send additional PDFs to disability@niagaraswim.org*

Cancelof
Remittance

Please provide to whom to remit reimbursement.
Make Check Payable to:*
All checks must be made out to a club.
Send Check to:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
By signing below, you attest that all information provided in your request is true and accurate. In addition, your request is in accordance with the Bylaws and Policies and Procedures of Niagara Swimming, Inc.
Signature*

Clear
Name of Signer*

First NameLast Name
Should be Empty:

Adaptive Coach Travel/Education Reimbursement Application

Contact Information

Meet/Event/Clinic Information

Attendee Information

Reimbursement Request

Remittance