Senior Athlete Reimbursement Form

Senior Athlete Reimbursement Form

Please submit one form per club per meet!
Contact Information

Please provide contact information for the person making the request.
Club Name*
Submitted by (Coach/Senior Chair)*

First NameLast Name
Email:*
example@example.com
Meet Information
Meet Category*
Name of Meet*
I agree that all listed athletes have been Ozark Swimming LSC members for at least 1 year or more:*

YesNo
I agree that each listed athlete swam at least one individual or one relay event (no time trials only)*

YesNo
Base Daily Rate
How many athletes are you submitting?*
Athlete Info
Athlete 1-Name *
Athlete 1-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 1-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 1-Total ($)
Athlete 2-Name *
Athlete 2-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 2-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 2-Total ($)
Athlete 3-Name *
Athlete 3-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 3-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 3-Total ($)
Athlete 4-Name *
Athlete 4-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 4-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 4-Total ($)
Athlete 5-Name *
Athlete 5-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 5-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 5-Total ($)
Athlete 6-Name *
Athlete 6-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 6-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 6-Total ($)
Athlete 7-Name *
Athlete 7-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 7-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 7-Total ($)
Athlete 8-Name *
Athlete 8-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 8-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 8-Total ($)
Athlete 9-Name *
Athlete 9-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 9-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 9-Total ($)
Athlete 10-Name *
Athlete 10-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 10-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 10-Total ($)
Athlete 11-Name *
Athlete 11-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 11-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 11-Total ($)
Athlete 12-Name *
Athlete 12-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 12-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 12-Total ($)
Athlete 13-Name *
Athlete 13-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 13-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 13-Total ($)
Athlete 14-Name *
Athlete 14-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 14-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 14-Total ($)
Athlete 15-Name *
Athlete 15-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 15-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 15-Total ($)
Athlete 16-Name *
Athlete 16-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 16-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 16-Total ($)
Athlete 17-Name *
Athlete 17-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 17-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 17-Total ($)
Athlete 18-Name *
Athlete 18-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 18-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 18-Total ($)
Athlete 19-Name *
Athlete 19-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 19-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 19-Total ($)
Athlete 20-Name *
Athlete 20-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 20-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 20-Total ($)
Athlete 21-Name *
Athlete 21-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 21-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 21-Total ($)
Athlete 22-Name *
Athlete 22-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 22-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 22-Total ($)
Athlete 23-Name *
Athlete 23-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 23-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 23-Total ($)
Athlete 24-Name *
Athlete 24-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 24-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 24-Total ($)
Athlete 25-Name *
Athlete 25-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 25-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 25-Total ($)
Athlete 26-Name *
Athlete 26-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 26-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 26-Total ($)
Athlete 27-Name *
Athlete 27-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 27-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 27-Total ($)
Athlete 28-Name *
Athlete 28-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 28-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 28-Total ($)
Athlete 29-Name *
Athlete 29-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 29-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 29-Total ($)
Athlete 30-Name *
Athlete 30-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 30-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 30-Total ($)
Athlete 31-Name *
Athlete 31-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 31-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 31-Total ($)
Athlete 32-Name *
Athlete 32-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 32-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 32-Total ($)
Athlete 33-Name *
Athlete 33-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 33-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 33-Total ($)
Athlete 34-Name *
Athlete 34-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 34-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 34-Total ($)
Athlete 35-Name *
Athlete 35-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 35-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 35-Total ($)
Athlete 36-Name *
Athlete 36-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 36-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 36-Total ($)
Athlete 37-Name *
Athlete 37-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 37-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 37-Total ($)
Athlete 38-Name *
Athlete 38-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 38-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 38-Total ($)
Athlete 39-Name *
Athlete 39-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 39-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 39-Total ($)
Athlete 40-Name *
Athlete 40-Participation*

Athlete had at least 1 individual eventRelay Only Swimmer
Athlete 40-Days Attended (Count from the Day Before 1st event through the Day of last event-time trials excluded) *
Athlete 40-Total ($)
Total Due to Club ($)
Club Grand Total ($)
Checks are payable to the club. This submission provides the itemized breakdown by athlete.
Club Address:

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 Ozark Swimming, Inc.
Signature

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First NameLast Name
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