Youth Support Reimbursement Application

Name of Participant *

First

Last

If you are applying for multiple participants, please submit separate applications for each of them.

Grade of Student *

Students in grades K-12 are eligible.

Email *

Phone Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Is the participant: *

TNC Shareholder
NVT Tribal Citizen
None of the above

Extracurricular Activity *

Affiliated Program (Official name of school, club, or organization) *

Program Start Date

Program End Date

Your Information

Receipient of Funds *

First

Last

How are you related to the participant? *

Self
Parent
Other

Relationship: *

Phone *

Email *

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Amount Requested and Supporting Documentation

Amount Requested *

Please add up qualifying expenses to the best of your ability.

Reported Expenses *

Examples of qualifying expenses: 1. Educational tutoring, conferences, and programs. 2. Camps - can include athletics, cheerleading, dance, band, and summer camps. 3. Extra-curricular activities - can include athletics, band, dance, and art (gloves, shoes, sports equipment, band instruments, dance wear, class ring, letterman jacket, etc.) 4. Educational opportunity fees - e.g., membership dues.

File Upload *

Click or drag files to this area to upload. You can upload up to 10 files.

Please provide documentation of expenses (bills, receipts, etc.). If you have a large number of receipts, please highlight or circle the expenses you are requesting reimbursement for. Make sure that receipts are legible and include you or your child's name is included for timely processing. If you need to upload additional files, please email them to info@tebughnafoundation.com.

Signature *

Clear Signature

Acknowledgment: I certify that the information provided is accurate and that the expenses listed were incurred for the extracurricular activity stated above. I understand that the Tebughna Foundation reserves the right to verify all submitted documentation before reimbursement is approved.