Tuition Reimbursement Form - Memorial Health System Page 2
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3Tuition Reimbursement Program
TUITION REIMBURSEMENT – SECTION I (Employee)
NAME: ____________________________
DEPARTMENT: _________________________________
POSITION: _____________________
ID#:_____________
CREDIT
TOTAL
TITLE OF COURSE
COST
BOOKS
FEES
HOURS
AMOUNT
1.
2.
3.
School offering course: _________________________________________________________________________
Educational Objectives: _________________________________________________________________________
Course to begin on: __________________________ To be completed: ___________________________________
Date of Expected Graduation (If Applicable): ________________________________________________________
Degree: (If Applicable): _________________________________________________________________________
By providing my signature below, I understand that should I separate voluntarily or involuntarily
from the organization, I will be responsible for repaying the amount of tuition awarded during the
12 months immediately prior to my separation.
Employee Signature
Date
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