Bulletin Plus :: Church Form

All forms must be submitted on a monthly basis by no later than the 15th of the following month. This should not include any future dates. Any forms turned in more than 1 month past the last meeting date will be declined. Please allow up to 2 weeks to receive your reimbursement.

First and Last Name

Phone

Email

Connect Group Leader's Name

Submitting Reimbursement Requests for the Month of

Childcare Worker Ratio & Reimbursement Rates:

• 1 to 3 kids- 1 worker at $30 per session.

• 3-8 kids- 2 workers at $60 per session.

• 9+ kids- 3 workers at $90 per session.

• 3 workers is the maximum that Centerpoint will reimburse for a Connect Group gathering.

Total Reimbursement Due

Please use the information above to calculate this dollar amount.

Date of Session

Amount Paid

Date of Session

Amount Paid

Date of Session

Amount Paid

Date of Session

Amount Paid

Date of Session

Amount Paid

Preferred Reimbursement Method (mailed check/direct deposit)

If you select direct deposit, our Finance Manager will contact you about filling out a direct deposit form.

I would like to be reimbursed via mailed check. I would like to be reimbursed via direct deposit.

Please provide your mailing address.

City, State Zip

Send Copy To (Your Email)