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Request for HSA Funds
Any request above $100 requires approval from HSA Board.
Please keep all receipts. (Original receipts must be turned into the HSA Treasurer.)
*Required
*
Indicates required field
Staff Member Name
*
First
Last
Date the funds are needed
*
Total amount requested
*
What is the rationale for the special project, excursion or materials requested?
*
Anticipated date(s) of excursion(s) or special project(s)
*
How is the request related to school goals?
*
Attach documentation to support your request, including list of materials/items
*
Max file size: 20MB
Make Check Payable to:
Name
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Contact Number
*
Contact Email
*
Submit