Make Reimbursement Payable To:

Name:

Address:

City:                                                                       Zip:
              
Home Phone :                                                       
              
Email Address:


Event Type :

C-Group, Leader Training, Gathering, etc:

Date:

Number of Children:

Number of Hours:

Amount:

For individual sitters, please use the chart below:

Number	Hours of Event
of Children	1	2	3	4
1	$7.00	$14.00	$21.00	$28.00
2	$7.50	$15.00	$22.50	$30.00
3	$8.00	$16.00	$24.00	$32.00
4	$8.50	$17.00	$25.50	$34.00

Group sitting of 5 or more children will be paid at a rate of $10.00 per hour.