Winston-Salem/Forsyth County Schools

Classified Employees 2016-2017 Tuition Reimbursement Scholarship Application

(coursework completed between January 2017 – June 2017)

PLEASE TYPE OR PRINT Please make additional copies as needed.

Name:

Last First Middle/Maiden

School/Location: ______

Highest Educational Level Achieved:

Grades: o 10 o 11 o 12

College: o 1 o 2 o 3 o 4

Other:

Work Experience:

Years (from-to) School/Department (include city/state) Assigned Role

Your Reason(s) for Enrolling in Course(s) – please check:

o to meet requirements for improving job performance

o to earn additional certification /license in

o to earn degree o GED o AA o BA o BS o MA in

at

area of degree program institution

o to earn certificate renewal credit for professional growth

o to expand my understanding/skills in my current assignment

o other (state reason)

I am applying for a Tuition Reimbursement Scholarship for these course(s):

Beginning/Ending Tuition

Course Title and Number College or University Dates of Courses Cost**

$

$

$

**Tuition cost for course only - exclude activity and other fees associated with the course(s)

ORIGINAL RECEIPTS* OR CANCELLED CHECKS MUST BE ATTACHED

*Receipts must have school name, your name and amount PAID – NOT DUE. College or University website with emblem will be considered original if paying online.

How will the course(s) address your professional career goals and our school system goals?

Comments/Recommendation of Your Supervisor:

Signature Date

Supervisor

Signature Date

Scholarship Applicant

Application Deadline: 5:30 p.m. on Thursday, June 22, 2017

Note: Forms received without ORIGINAL RECEIPTS OR CANCELLED CHECKS will be returned. Internet receipts must include name and payment made.

Forms must be complete with signature and received before the deadline for consideration.

Please return this form to Matt Dixson c/o Joette Unks in Human Resources.

You may submit the form via school mail, U.S. mail (P.O. Box 2513, Winston-Salem, NC 27102-2513) or by hand delivering to the receptionist at the Administrative Center, 475 Corporate Square Drive, Winston-Salem, NC 27105. If you have any questions, please call (336) 748-4079.