Hockomock CPC

FY’06 Application for Reimbursement for Field Trip Costs for CPC Subsidized Children

This form is to be submitted for uncollected field trip/enrichment costs for CPC children enrolled, incurred between 7/1/05-6/30/06. We reserve the right to verify attendance of each child on the date of field trip/enrichment program from attendance sheets submitted to Self Help Inc.

Program Name:

1. Description of Field Trip/Enrichment Program

Date of Trip/Program

Names of CPC children who participated

Cost per child $ x total# of CPC children = requested reimbursement $

2. Description of Field Trip/Enrichment Program

Date of Trip/Program

Names of CPC children who participated

Cost per child $ x total# of CPC children = requested reimbursement $

3. Description of Field Trip/Enrichment Program

Date of Trip/Program

Names of CPC children who participated

Cost per child $ x total# of CPC children = requested reimbursement $

Please make copies of this form if you have additional field trip/enrichment reimbursement requests

Total amount of Reimbursement $

Reimbursement should be made out to the following:

Program/Person Name:

Address:

Copies of proof of payment for each trip/enrichment program must be submitted with this application by June 30, 2006. Applications will be processed on a first come first serve basis. Reimbursement is dependent on funding available

Applications should be sent to:

Self Help Inc./Hockomock CPC

780 West Main Street

Avon, MA 02322

Fax 508-583-3808