Stipend Pay Request
(After-School, Homebound, and PD)
Name
*
First Name
Last Name
Email Address
*
example@example.com
Location of Activity
*
Please Select
Central Office
Johnson Elementary
Lexington Elementary
Office of Exceptional Services
Scottsburg Elementary
Scottsburg High School
Scottsburg Middle School
Vienna-Finley Elementary
Grace Christian Academy
Virtual
Your Normal School Day Role
*
Please Select
Aide or Tutor (Classroom, Sp Ed, Title I)
Counselor/Social Worker (Cert. Contract)
Teacher (Cert. Contract)
Other
Activity Type (Be specific in 10 words or less)
*
Total number of hours
Date(s) of Activity
*
Person who can verify activity
*
Please Select
Charles Bottorff
Carrie Carter
Tiffany Copple
Jeff Cox
Christy Davis
Keri Hammons
Denyael Owsley
Nick South
Eric Copple
Does admin or director approve submission details?
Yes
No
Admin Signature
Fund
Please Select
Title I
Title II
Title IV
Food Service
Central Office Signature
Submit
Should be Empty: