Childcare Reimbursement

Childcare Reimbursement

Use this form to be reimbursed for childcare expenses related to small group meetings.

Name First Last
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone - (###) - ### ####
Email
Small Group Leader
Sitter's Name
Number of Children

How many children were being watched by the sitter.
Date of Event / MM / DD YYYY
Starting Time : HH MM AM/PM
When did the sitter arrive?
Ending Time : HH MM AM/PM
When did the sitter Leave?
Hours Worked

How many hours did the sitter work?
Amount paid

How much are you requesting to be reimbursed?
Additional Comments
Pay Rates

The following pay rates will be reimbursed up to 4 hours/event.
1 Child $7.00/hr (max 4 hours)
2 Children $7.50/hr (max 4 hours)
3 Children $8.00/hr (max 4 hours)
4 Children $8.50/hr (max 4 hours)
5 Children $9.00/hr (max 4 hours)