Individual Childcare Partial Reimbursement Form

Instructions: 1. This form is to provide childcare financial assistance for ACTIVE participants in an approved group for The Church at LifePark. 2. LifePark will subsidize eight dollars and fifty cents ($8.50) per hour for a max of one sitter for three (3) hours per week, per family. 3. Each participants is responsible for hiring and coordinating their own sitter in their home as well as complete and submitting this form in a timely manner. PLEASE FILL OUT AND SUBMIT MONTHLY. *Note: forms submitted three (3) months past the meeting date, will not be accepted.

Your name *

Email address *

Address *

Which LifeGroup do you attend? *

Date (Meeting 1) *

Number Of Hours (Meeting 1) *Not to exceed 3 weekly *

Amount To Reimburse (Meeting 1) *Not to exceed $25.50 weekly *

Date (Meeting 2)

Number Of Hours (Meeting 2) *Not to exceed 3 weekly

Amount To Reimburse (Meeting 2) *Not to exceed $25.50 weekly

Date (Meeting 3)

Number Of Hours (Meeting 3) *Not to exceed 3 weekly

Amount To Reimburse (Meeting 3) *Not to exceed $25.50 weekly

Date (Meeting 4)

Number Of Hours (Meeting 4) *Not to exceed 3 weekly

Amount To Reimburse (Meeting 4) *Not to exceed $25.50 weekly

Date (Meeting 5)

Number Of Hours (Meeting 5) *Not to exceed 3 weekly

Amount To Reimburse (Meeting 5) *Not to exceed $25.50 weekly

Total amount to reimburse *

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