Ref reimbursement form

HOPKINTON YOUTH SOCCER
Request for Course/Certification Reimbursement

Name of person who took the course:_____________________________________ Address:____________________________________________________________ Phone:____________________________ e-mail:___________________________ D.O.B.______________ Current Age:_______________ School Grade:_________ Name of Course (i.e. coach level E)________________________

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Location:__________________________ Date:________Did you pass the test? Y N Course Fee Amount:_______________________ (late fees are not reimbursed) Other Amount Requested:___________________explain:
Total Amount Requested:____________________

Please write clearly the name and address of the person to whom the reimbursement check should be made out to (or same as above): ________________________________
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HYS will reimburse coaches for initial certification course fees, annual recertification fees and annual national fees assessed for certification, if the person passes the test, and has started to actively work for Hopkinton Youth Soccer. By signing below, you are certifying that you took the course and paid the fees as described above, and you agree to work for HYS in the coming year.

Signature of Applicant:______________________________ Date:________________ Signature of Parent/Guardian (if under 18)___________________________________

Please mail to HYS PO Box 69 Hopkinton, MA 01748 Office Phone: 508-435-5523