Childcare Supplement Form
Please, fill out the form for only ONE event at a time. REIMBURSEMENTS MUST BE SUBMITTED WITHIN TWO WEEKS OF THE EVENT FOR PAYMENT TO OCCUR.
Name of Event *
(e.g., Small Group)
Your answer
Date of Event *
MM
/
DD
/
YYYY
Name *
Your answer
Mailing Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone *
Your answer
Amount to be reimbursed *
We will reimburse up to $10 per hour.
Your answer
Submit
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