Missions Education Reimbursement

This form and validating documentation must be submitted with a requisition to the administrative committee district mission board before the synod processes an education reimbursement.
Unless you are submitting once for the entire year, you will have to submit multiple times for the same student if monthly, quarterly or semester.
Complete one form per child.
A field marked with a red asterisk is required.

Student Information

Student name*

First Last

Mission field*

School attending*

School name*

School address*

Address line 1 Address line 2 City State Zip code

Foreign school name and address*

School Expenses

Elementary school*

$750 LES towards actual tuition for the first child
$500 LES towards actual tuition for the second child
$250 LES per third child
$250 LES per fourth child
$250 LES per fifth child

High school*

$1,250 LHS towards actual tuition for the first child
$850 LHS towards actual tuition for the second child
$500 LHS per third child
$500 LHS per fourth child
$500 LHS per fifth child

School tuition
All amounts are in United States dollars.

Time period*

Enter Monthly, Quarterly, Semester or Yearly

Actual charges*

Awards/Scholarships*

Your responsibility*

WELS reimbursement*

Attach a school statement showing scholarship/award monies received.*

• File extensions allowed: pdf, doc, docx, jpg, xls, xlsx, zip
• Maximum file size allowed: 4MB

Drop files here or

Accepted file types: pdf, doc, docx, jpg, xls, xlsx, zip, Max. file size: 4 MB.

Data Privacy & Permission*

I AGREE with the terms of the WELS Privacy Policy.

NOTE TO EU CITIZENS, RESIDENTS, TOURISTS, AND OTHER PERSONS TEMPORARILY IN THE EU:

By submitting this form you consent to any and all information you provide and submit via the site being sent to the United States of America. The United States has not sought nor received a finding of “adequacy” from the European Union under Article 45 of the GDPR. WELS relies on derogations for specific situations as set forth in Article 49 of the GDPR. You are also informed that the United States presently does not have an adequate level of personal data protection as determined by the European Commission’s adequacy decision on October 6, 2015 (case c-362/14) and articulated in the European Union’s General Data Protection Regulation and has not received a similar designation of adequacy by any other foreign data protection authority. You agree to the transfer of your data and personal data to the United States, however, to be used in accordance with WELS Privacy Policy.

Request prepared by*

Date*

E-mail*

A confirmation e-mail will be sent to the e-mail provided.

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