Mazama Climb Reimbursement Form

Mountain, Route *

Summit Date * +

Leader *

Assistant Leader *

Leader email address. We'll email you a copy of this form for your records. *

Are you submitting an incident report to the Risk Management Committee for this climb? (Incidents include injuries, near misses, behavioral problems, or any Search and Rescue Operations.) Link to form.

yes

Mileage Reimbursement

Mileage reimbursement is .14 per mile. The activity leader and activity assistant may submit reimbursement for mileage if they drive or reimburse the driver.

Maximum reimbursement for any activity leader/assistant, regardless of driving distance, is $126. (900 miles at .14/mile; Reference mileage document: Link to Mileage Rates)

Mileage can either be reimbursed or donated. Donated mileage is tax-deductible.

Activity Leader

Leader Mileage

Reimburse

Donate

Leader Miles Driven (max reimbursement is $126; 900 miles at .14/mile)

Leader Mileage Total

0.00

Leader Street Address *

Leader City *

Leader State *

Leader Zip *

Activity Assistant Leader

Assistant Leader Mileage

Reimburse

Donate

Assistant Leader Miles Driven (max $126; 900 miles at .14/mile)

Assistant Leader Mileage Total:

0.00

Asst. Leader Street Address *

Asst. Leader City *

Asst. Leader State *

Asst. Leader Zip *

Asst. Leader Email Address *

Permit Reimbursement

Did your activity require permits? *

Yes

The peaks that currently require permits are Mt. Rainier, Mt. Adams, Mt. St. Helens, and Mt. Shasta. Current rates are:

Mt. Rainier (25+: $48/each; 24-: $34/each)

Mt. Adams (Weekend: $15/each; Weekday: $10/each)

Mt. St. Helens ($15/each)

Mt. Shasta ($25/each)

Activity Leader

Enter the amount of the leader permit fee (reference permit fees listed above)

How many additional Mt. St. Helens permits were purchased by the leader?

Additional Reservation fees (if independent from each permit, such as Mt. St. Helens)

Leader Permit Total:

0.00

Attach a copy of the permit receipt(s). This is required for reimbursement.

Activity Assistant Leader

Enter the amount of the assistant permit fee (only if the assistant paid directly for their permit)

Additional Information

Any other expenses for the leader or assistant leader must be requested from the climbing committee using the Mazama Committee expense authorization request form. Reimbursement for safety gear left on route may also be requested. Include a description of the item, value and reason it was left.

Thanks!
Please check your information carefully, and click the "submit" button below to send your information to the Mazamas.