Student Reimbursement Form Students may use this form to receive reimbursement from the Enrichment Office (EO) for: Food and/or supplies sponsored by student organization events; or Other expenses being reimbursed to students by the EO such as conference fees, registration fees, etc. Students are asked to submit one PDF or Word document that includes all receipts. Individual receipts must itemize purchases; e.g., a restaurant receipt must list each item ordered with tax and total amount of bill. Receipts must indicate proof of payment. Once this form is submitted with receipts, the student will receive his/her reimbursement at the address he/she provides below in about three weeks. Questions? Contact Ana Gregory.I. Student InformationThis is the person receiving the reimbursement.Today's date* MM slash DD slash YYYY Name of student* First Last Student's email address* Enter Email Confirm Email Student's address* Street Address City State / Province / Region ZIP / Postal Code The check will be sent to the address above.II. Reimbursement for Food for Student Organization EventComplete this section if you are requesting reimbursement for food for an event that your organization held.Date of event MM slash DD slash YYYY Name of event Brief description of event Number of event attendeesType of attendees at your event Students Faculty Guests (e.g., outside speakers) Amount of reimbursement (for event)Upload receipts from your event (in one PDF or Word document) Drop files here or Select files Max. file size: 100 MB. Note on receipts: Submit your receipts in one PDF or Word document. Receipts must show proof of payment.III. Reimbursement for Student Organization SuppliesIf you are requesting reimbursement for supplies for your organization, complete this section.Description of supplies Amount of reimbursement (for supplies)Upload your receipts for your supplies (in one PDF or Word document) Drop files here or Select files Max. file size: 100 MB. Note on receipts: Submit your receipts in one PDF or Word document. Receipts must show proof of payment.IV. Reimbursement for Conference Fees, Registrations, etc.If you are requesting reimbursement for conference fees or registrations, complete this section. Description of conference fees, registrations, etc. Amount of reimbursement (for conference fees, registrations, etc.)Upload your receipts for your registrations/fees (in one PDF or Word document) Drop files here or Select files Max. file size: 100 MB. Note on receipts: Submit your receipts in one PDF or Word document. Receipts must show proof of payment.V. Organization Affiliationindicate the student organization that you are affiliated with in connection to the expenses submitted above. iF YOU ARE NOT affiliated with an organization, indicate "Individual not affiliated with student organization" below. Organization (Host/Sponsor of Event/Supplies)* BUATP (Advocacy Training Program) Bridge Clinic Project Family Medicine Interest Group (FMIG) Global Health Equity Program (GHEP) Homeless Health Immersion Experience (HHIE) Integrative Medicine Interest Group Outdoor/Outreach Club Outreach Van Project (OVP) Outreach Van Project (OVP) & Homeless Health Immersion Exp. (HHIE) COMBINED event MedImpact Program PumpStart Program SideKicks Program Individual not affiliated with student organization NotesIf needed, please include any clarifying information regarding your reimbursement above.