NISRA Reimbursement Request

Northern Illinois Special Recreation Association Reimbursement Request Form

Village of Algonquin
Northern Illinois Special Recreation Association (NISRA) offers a variety of recreational opportunities for individuals with special needs. Those individuals who reside within the Village of Algonquin’s residential boundaries and participate in NISRA programming are eligible for the Village’s NISRA Reimbursement Program. Non-Residents and/or unincorporated Residents of Algonquin do not qualify for reimbursement. This program will reimburse Algonquin Residents the difference between in-district and out-of-district fees less any scholarships received for participation in NISRA programming. To receive reimbursement, participants must complete this form and submit supporting documentation within the same calendar year the program has been conducted. Reimbursements will only be sent once a course is completed. Reimbursement checks are sent directly to the address listed on this form and may take up to 30 days to receive. Should you have any further questions and/or concerns, please contact the Village of Algonquin Recreation Department at recreation@algonquin.org or (847) 658-2716.
Participant's Name*

First NameLast Name
Parent/Guardian's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Course Information*
Please attach an invoice/receipt showing payment for the above-listed programs to this form. *

Cancelof
I have read and fully understand the information listed on this form.
Signature of Parent/Guardian (if participant is under 18 years of Age)*

Clear
Date*

MonthDayYear
* Office Use Only *
Total Reimbursement:
REC DI ORG: 01101100 OBJ: 42234
Should be Empty:

Northern Illinois Special Recreation Association Reimbursement Request Form