Fillable District 75 Therapist Tuition Reimbursement Form printable pdf download

District 75 Therapist Tuition Reimbursement Form

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Log No.:

District 75 Therapist Tuition Reimbursement Form

Print Form

Instructions: Completed applications must be forwarded with appropriate documentation (i.e. copy of workshop brochure, signed PD-19

if necessary, proof of payment and certificate of completion or student transcript.

IDENTIFYING INFORMATION

Last Name:

First Name:

MI:

Home Address:

Apt No.:

City:

State:

Zip Code:

Home Telephone No.*:

Employee Reference No.*:

e-Mail Address:

School

School Address:

(ex. K004)

Related Service

Physical Therapist

Occupational Therapist

Area:

(DOE) - Lvl 1

(DOE) - Lvl 2

(DOE) - Lvl 1

(DOE) - Lvl 2

Physical Therapist

Occupational Therapist

(DOE) (HOURLY) - Lvl 1

(DOE) (HOURLY) - Lvl 2

(DOE) (HOURLY) - Lvl 1

(DOE) (HOURLY) - Lvl 2

COLLEGE/UNIVERSITY/AND/OR WORKSHOP/CONFERENCE INFORMATION

Degree or

Degree

Presently Held:

Certificate Being Sought:

College/University or

Address:

Institute of Attendance:

Semester of Attendance:

Fall

Spring

Summer

List Job-Related Course or Workshop:

Date From:

Tuition for Course:

NOTE: Late fees, books, membership fees and program fees are not paid for by Tuition Reimbursement and are the responsibility of the

applicant.

I have not previously submitted a tuition reimbursement claim for attendance at this course/workshop and understand that duplicate submissions will be rejected and

not reimbursed.

APPLICANT'S SIGNATURE: ____________________________________________

DATE: _______________

OFFICE OF CLINICAL AND SUPPORT SERVICES

I have reviewed the enclosed documentation and have determined that the above listed course/workshop is job-related and is provided by a legitimate institution. This

request for Tuition Reimbursement is deemed appropriate and hereby approved for reimbursement.

_____________________________

____________

OT/PT Supervisor

OT/PT Supervisor's Signature

Date

Sfx 1:

Supporting Documentation File: ______________________________________

Sfx 2:

Entered By: _______________________________

Date: ______________

Sfx 3: