Goalie Development Reimbursement Request (Haldimand Minor Hockey)

Goalie Development Reimbursement Request

* NEW THIS SEASON! * HMHA will reimburse current River Kings Goalies for goalie instruction of their choosing from an accredited instructor to a maximum of $150 per goalie, per season. Please use this form to request Goalie expense reimbursements. Be sure to list the vendor's name and expense description. Remember to attach ALL DETAILED receipts to this form (required for payment). This form will be forwarded to our Development Coordinator and Treasurer. Please allow at least 2 weeks for payment.

Contact Information

All Fields Mandatory in this Section

First Name:^*

Required

Last Name:^*

Required

Team / Division:^*

Required

Contact Email:^*

Required

Example: [email protected]

Cell Phone:^*

Required

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

Who to make the cheque payable to:^*

Required

Name or Team Account

Goalie Expense #1

Expense to be Considered for Reimbursement. All Fields Mandatory in this Section

Date of Expense:^*

Required

Vendor Name / Expense Description:^*

Required

Expense Amount ($):^*

Required

Attach Receipt:^*

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

Goalie Expense #2

Expense #2 to be Considered for Reimbursement

Date of Expense:

Vendor Name / Expense Description:

Expense Amount ($):

Attach Receipt:

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

Goalie Expense #3

Expense #3 to be Considered for Reimbursement

Date of Expense:

Vendor Name / Expense Description:

Expense Amount ($):

Attach Receipt:

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

Goalie Expense #4

Expense #4 to be Considered for Reimbursement

Date of Expense:

Vendor Name / Expense Description:

Expense Amount ($):

Attach Receipt:

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

I certify that all expenses listed above were incurred for goalie training and I am requesting to be reimbursed for these expenses up to $150.

Agreed^*

Goalie Development Reimbursement Request (Haldimand Minor Hockey)

OMHA Digital Network

Contact Information

Goalie Expense #1

Goalie Expense #2

Goalie Expense #3

Goalie Expense #4