Fill - Free fillable Child Care ReimbursementFA17 (Columbia College) PDF form

Month of: Year:

Student (Parent) Name: Student ID #: Phone Number:

Mailing Address: City: Zip Code:

Child Name: Child Age:

Provider Name: Provider Phone:

DIRECTIONS: Fill in one form per child. Write down and initial the time you drop your child off and when you pick your child up (Circle AM or PM). Indicate reason for

care by circling CLASS or STUDY. Total the number of hours childcare was provided each day. At the end of the month, add up all the hours and indicate the total

number of hours childcare was provided for the month. Reimbursement must be filled out completely and accurately. Forms must be received by the 5th of each

month or your payment will be delayed.

DATE

CHILDCARE

BEGINS

PARENT

INTL'S

CHILDCARE

ENDS

REASON

PARENT

INTL'S

TOTAL

HOURS

DATE

CHILDCARE

BEGINS

PARENT

INTL'S

CHILDCARE

ENDS

REASON

PARENT

INTL'S

TOTAL

HOURS

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

CLASS

STUDY

TOTAL NUMBER OF HOURS CHILDCARE WAS PROVIDED FOR THE

MONTH

I verify that the information above is true and correct and the above

childcare is provided solely for the purpose of class attendance, study

time, counseling appointments, and workshops. I verify that I have not

previously requested payment or received payment from any other

source for these requested childcare costs.

Provider Signature

Date

Student (Parent) Signature Date

OFFICE USE ONLY

Hourly rate: $8

Max per family: $150

Total Hours Claimed :

Reimbursement Amount:

Total Hours Allowed :

Date Processed:

Unpaid Amount:

SpringFallSemester:

DATE STAMP RECEIVED

Columbia College CARE PROGRAM u 11600 Columbia College Drive, Sonora CA 95370 u (209) 588 - 5130

CHILDCARE REIMBURSEMENT FORM

September 2017 - TH

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Child Care ReimbursementFA17 (Columbia College)

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