Healthy Choice Reimbursement Form

Healthy Choice Reimbursement Form
Each House is allotted up to $250 per month reimbursement for Healthy Choice items. Please do not request more, even if the previous months were less than $250. The grant that helps us support you will only pay on a reimbursement basis according to this guideline.
- You may submit this form monthly, or quarterly (every 3 months) for reimbursement.
- Please do not submit greater than 3 months’ worth of reimbursement requests at a time.
- Only acceptable Healthy Choice items will be reimbursed.
Name

First NameLast Name
House
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Month(s)
Total Each Month
Grand Total
Please attach receipts, and highlight all products for reimbursement:

Please upload an image or PDF
Cancelof
Should be Empty: