Community Group Childcare Reimbursement Form

Please fill out the following information WITHIN 30 DAYS of your group meeting date(s) for reimbursement. This form can cover up to four meetings.

Your name *

Email address *

Meeting Dates

Please enter the dates you attended your group and used childcare. We only reimburse for one meeting per week. As a reimbursement, you are acknowledging that you have already used and paid for a sitter and this is indeed a reimbursement. The church will not forward any payments for future dates. For any questions, e-mail Dave Allee at dave.allee@thechapelbr.com.

How many weeks are you submitting for reimbursement? *

1 week

2 weeks

3 weeks

4 weeks

Group Leader Name *

Meeting Date - Week 1 *

Meeting Date - Week 2

(if applicable)

Meeting Date - Week 3

(if applicable)

Meeting Date - Week 4

(if applicable)

Reimbursement Information

Rates for childcare are:
$15 per week for up to three children.
$20 per week for four to six children.
$25 per week for seven to nine children.
$30 per week for ten or more children.
Please allow two weeks from submission for checks to be processed and mailed.

Validation of Payment *

I acknowledge that I have already paid a sitter (or sitters) NO LESS than the amount(s) I will be reimbursed.

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