Sachem 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:
- 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 $
- 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 $
- 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 and reimbursement is dependent on funding available.
Applications should be
sent to:
Self Help Inc./Sachem CPC