SCH PACE Application

Employee/Retiree Name Employee/Retiree Name First Last
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Draw or Type

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Full Name

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Spouse Name (If eligible for reimbursement) Spouse Name (If eligible for reimbursement) First Last
Home Address Home Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone - ### - ### ####
Building/School
Email Address
Name of Facility
Facility Address Facility Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Facility Phone Facility Phone - ### - ### ####
Date Joined Date Joined / MM / DD YYYY
Membership Expires Membership Expires / MM / DD YYYY
Contract Terms and Cost $ Dollars . Cents
(Upload a File) Proof of Payment

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(Upload a File) Attendance Verification

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(Upload a File) Doctor's Note
MAKE A COPY FOR YOUE RECORDS

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