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