3. 

5. K-12 students and families in Coconino County that have tested positive for COVID-19 since July 1, 2021 can request wraparound services provided through the Vaccine Equity Grant. Simply fill out the form, attach an itemized receipt if needed, and submit. Please note that reimbursement may take up to six weeks. If you need assistance or have questions, please contact Lee Irby (lirby@coconino.az.gov or 928-679-8065). Haga clic aquí para el formulario de Solicitud de servicios integrales de COVID-19 en español.

7. Name of Requestor*
8. Date of Request
10. Mailing Address
12. City
13. State
14. Zip Code
16. Email Address
17. Phone*
19. Reimbursement requested for (select all that apply):

    1. Hotel/Short-term Lodging (itemized receipt required)
    2. Groceries
    3. Laundry Services (itemized receipt required)
21. Description of Service
23. When was your family impacted by COVID-19?
25. Limitations/Restrictions
    • Hotel reimbursement limited to $155 a night for up to 14 nights.
    • Grocery reimbursement/gift card limited to $200.
    • Laundry services limited to $25 per service for up to four services in a two-week period.
    • Each support service may be requested by individual households once per school year.
27. Itemized Receipt
    • Requests for reimbursement for lodging, grocery, and laundry services require an itemized receipt.
    • Requests for a grocery gift card does not require itemized receipt.
    • Additional documentation may be requested to complete reimbursement.
29. Upload 1 (if needed)
30. Upload 2 (if needed)
31. Upload 3 (if needed)
33. Attestation
    • I attest that myself or someone in my family tested positive for COVID-19.
    • I attest that someone in my family is a K-12 student in Coconino County.
35. Signature
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit Submit and Print

* indicates a required field