Tribal wellness support application Name * First Name Last Name Email * Tribal Enrollment Number Mailing Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Select the Item that was Purchased * Rec Center gym pass Swimming Passes NSHC Camp department related fees Sports fees & Supplies Cultural related Courses offered by NWC (Nome only) Other Health/Wellness Did you submit receipts? * All submitted receipts for reimbursement are to be sent to tc.sol@kawerak.org Yes, I submitted No, I did not submit If Other, please explain If you selected NSHC Camp department related fees please list what it was for Amount Requested for Reimbursement Signature By signing below, I understand that if this application is approved, my check will be issued during normal every other Friday check issuance and then mailed to the address provided above. No hand deliveries, no exceptions. Today's Date MM DD YYYY Thank you!