Spencer Hospital Employee Tuition Assistance Application

Applications to be returned to HRD before the deadlines below and prior to the class start date (no late applications will be accepted).

All fields marked with * are required.

Applicant Information

First Name

Middle Name

Last Name

Employment Status

School Information

Type of Degree

AA/ADN
Bachelors
Masters

Declared Major (What Area of Study)

Area of emphasis for your graduate program

If in a Graduate Degree Program:

CRNA
Nurse Practitioner
PA
Other

Degree Completion Date

School

Title of Certification

Certifying Agency

Date of Initial Certification Exam

Please Include

1. A copy of the school statement of fees, showing the amount of tuition and related course expenses, or a copy of a statement of costs from the certifying agency.

2. Documentation of additional grants, scholarships, and other such monies you are scheduled to receive during that school period.

3. Describe how these educational opportunities will enhance your ability to perform your present job at Spencer Hospital or help qualify you for another position at Spencer Hospital.

Course Information

Title of Course 1

Course #

Date Course Begins

Date Course Ends

# of Credits of Course

Title of Course 2

Course #

Date Course Begins

Date Course Ends

# of Credits of Course

Title of Course 3

Course #

Date Course Begins

Date Course Ends

# of Credits of Course

Title of Course 4

Course #

Date Course Begins

Date Course Ends

# of Credits of Course

Total Tuition Expenses (does not include books or activity fees)

If requests exceed the budgeted amount, requests may be paid based on a percentage of available funds.

Budgeted full-time employees	AA Degree or Initial Certifying Exam: 50% of eligible expense, up to $2,000 per fiscal year
	Bachelor Degree: 75% of eligible expense, up to $3,000 per fiscal year
	Graduate Degree: 75% of eligible expense, up to $4,000 per fiscal year

Budgeted part-time and weekend package employees	AA Degree or Initial Certifying Exam: 50% of eligible expense, up to $1,000 per fiscal year
	Bachelor Degree: 75% of eligible expense, up to $1,500 per fiscal year
	Graduate Degree: 75% of eligible expense, up to $2,000 per fiscal year

Tuition Assistance Agreement

Spencer Hospital provides a tuition assistance program as an employee benefit to assist and encourage the development of employees to their maximum potential, both to ensure quality performance in their present job assignment as well as to prepare for potential increased responsibilities.

I, the undersigned, a recipient of Spencer Hospital tuition assistance, understand that, after successful completion of the course(s) or initial certifying exam, if I am terminated for cause or fail to comply with the repayment obligations stated below, I agree to pay the Hospital as liquidated damages the total amount of financial assistance received plus interest.

Failure to work on a full-time or part-time basis for SH:
1. Certifying Exam: one (1) full year after successful completion of the initial certifying exam.
2. AA degree: one (1) full year after completion of the course(s)
3. Bachelor's degree: two (2) full years after completion of the course(s)
4. Graduate degree: three (3) full years after completion of the course(s)
Course grade not reported to Human Resource Development within 60 days of course completion. (Repayment is only required for the specific course that is not reported).
Receipt of an incomplete grade or grade lower than a C for undergraduate courses or a B for graduate courses. (Repayment is only required for the specific course that does not meet this grade requirement).
Dropping of any course (Repayment is only required for the specific course that is dropped).

The liquidated damages to be paid to the Hospital shall become due in full and payable immediately upon the breach of this Agreement. By signing this agreement, I authorize Spencer Hospital to deduct from my net pay any amounts necessary to fulfill any repayment obligation that I may have. Ten percent annual interest will be added if liquidated damages are not paid in full immediately.

I further understand that tuition assistance may result in additional taxation to me as income and in additional withholding from my regular wages.

The tuition assistance program has been fully explained to me, and I have had an opportunity to ask questions, which have been answered to my satisfaction.

Signature

Today's Date