Hoosier Explorers Online Trip Reimbursement Form Field Trip Fund Trip Reimbursement Form Submit your reimbursement request after your trip. Teacher Name ( First and Last)* Teacher Email Address* Grade*Fourth GradeName of School* School District* School Phone Number (with area code)* School Address to Mail Reimbursement Check To:*School/District Name Attention to: Street City, State, & ZIP CodeField Trip Destination (Must be within Indiana)* Estimated number of students* Date of Field Trip* MM slash DD slash YYYY Number of participating students* Number of participating adults (teachers, chaperones)* Cost of Drivers* Number of Hours Worked x Hourly Wage = Driver CostCost of Benefits* FICA + Social Security = Driver BenefitsCost of Fuel Total Miles x Cost per Gallon of Fuel = Fuel CostTotal Cost of Transportation* Cost of Drivers + Cost of Benefits + Fuel Cost = Total Cost of TransportationUpload Your File(s) Drop files here or Select files Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 50 MB, Max. files: 10. Pictures or Student Work Product Relating to Trip, Max 10 Files. (Permitted files types include, jpg, gif, png, pdf, doc, docx)NameThis field is for validation purposes and should be left unchanged.