Childcare Reimbursement Form

Date of Group Meeting *

Name of Childcare Provider(s) *

Number of children *

Groups of 5 or more children will be paid at a $10 per hour flat rate.

Number of hours *

Maximum reimbursement of 3 hours per meeting. If the meeting runs longer than 3 hours, the group leader must pay the child care provider for the additional time according to the rate below.

Make check payable to: (group leader) *

Dollar amount requested *

Address to mail check if not previously provided: *