Tuition Waiver Form - Elms College
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1
2Tuition Waiver Form
A Tuition Waiver Form must be completed each
semester in which enrollment is requested.
Employee Information – Please Print
_________________________________________
Employee Name
Faculty
Staff
____________________________________
Employee’s Department
Full-Time
Part-Time
Relationship to Employee:
Self
Spouse
Dependent Child (see definition of Qualifying Child on reverse side of form)
Student Enrollment Information – Please Print
___________________________________
___________________
Student’s Name
Dependent’s SSN
______________________________
___________________________________
Home Address
No.
Street
City
State
Zip Code
Home Phone # ___________________________
Cell # _____________________
_______
Year
Fall
Spring
Summer I
Summer II
Weekend I
Weekend II
Weekend III
Student Status
Full-Time
Part-Time
Graduate
Undergraduate
Non-Degree
Complete the course information only if the employee is the student.
Dept ___________
Course Title ___________________________
# of Credits _____
Day & Time
Dept ___________
Course Title ___________________________
# of Credits _____
Day & Time
Dept ___________
Course Title ___________________________
# of Credits _____
Day & Time
Employee Certification
I certify that the above information is true, correct and complete. If this Waiver is for your dependent child, is the child age 23 or younger and eligible
to be claimed as a dependent on your Federal Form 1040 U.S. Income Tax Return for the year in which the tuition waiver applies?
YES
NO
Release Time Approval
The signature of the employee’s supervisor is required if the employee is enrolled in a course that meets during regular work hours and the
employee is requesting Release Time. Any release time authorized must be made up by the employee.
___________________________________________________________________________________
_____________________________________
_________________________________________________________________________
_____________________________________
Employee Signature
Date
Supervisor’s Signature Approval
Date
Please submit the completed Tuition Waiver Form to Human Resources prior to the start date(s) of the class(es).
____
HR Use Only:
Full-Time EE
Part-Time EE
Hrs./Wk
Six (6) Months of Service
Yes
No
The above named employee is eligible for the tuition waiver benefit. ____________________________________________________________
HR Director or Authorized Designee
Date
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