Clinic Rebate Form (Durham West Girls Hockey)

Clinic Rebate Form

DWGHA CLINIC REBATE FORM- To make sure no volunteer is out of pocket for clinics. Submission Deadlines are: December 1st, 2016 Payment to be received by January 1st, 2017. YOU MUST USE A SEPARATE FORM FOR EACH CLINIC ATTENDED

This rebate is for the following:

Personal Details

Name:^*

Required

Address:^*

Required

City:^*

Required

Postal Code:^*

Required

Phone #:

Example: ###-###-####

Email:^*

Required

Example: [email protected]

I am currently a Member and/ or Support Staff of the following team

Team Name: ^*

Required

Division:^*

Required

Role on Team^*

Required

Actual Clinic Date: ^*

Required

Clinic Location:^*

Required

Payment Information

Method of payment for clinic:^*

Required

Cost of Clinic:^*

Required

Documentation

Photos, Word, & PDF Files Accepted.

Upload Receipt^*

Allowed extensions: .jpeg, .jpg, .png, gif, .pdf, .doc, .docx.
Maximum # Files: 1. Maximum File Size: 4MB.

A receipt is MANDATORY for reimbursement.

Clinic Rebate Form (Durham West Girls Hockey)

Personal Details

I am currently a Member and/ or Support Staff of the following team

Payment Information

Documentation

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