APPLICATION FOR DEPENDENT TUITION WAIVER BENEFIT

Name of Employee/Annuitant:

Employee First Name *

Employee M

Employee Last Name *

Employee ID 🛈

Email Address * 🛈

Employing Location * 🛈

Kutztown University

Office of the Chancellor

Relationship of Student to Employee/Annuitant: * 🛈

Dependent Child

Spouse

KU Work Group * 🛈

APSCUF

COACHES

MANAGEMENT

SCUPA

KU Attending University: *

OOC Work Group * 🛈

MANAGEMENT-OOC

AFSCME-OOC

ANNUITANT-OOC

OOC Attending University: *

Name of Student:

Student First Name *

Student M

Student Last Name *

Student ID *

SEMESTER (PLEASE CHECK ONE) *

Academic Year

Does this student have an undergraduate degree from any college/university? * 🛈

Yes

No

Is DEPENDENT CHILD 25 years of age on the first day of semester? * 🛈

Yes

No

Is this the student first semester attending a PASSHE school? * 🛈

Yes

No

Date of Birth * +

Is dependent or spouse on your medical benefits plan? * 🛈

Yes

No

Please select your preference to submit the proof of age document. * 🛈

Attach a file

Deliver in person

Fax to HR private line at 610-683-4881

Other Other

Attached a proof of age document. * 🛈

Please contact Human Resources at 610-683-1353 for assistance.

Note: Your tuition waiver will be held until Human Resources received the proof of age document. Please bring a copy to the Kemp Building as soon as possible.

ATTENTION: INDEPENDENT STUDY / INDIVIDUALIZED INSTRUCTION COURSES ARE NOT COVERED BY TUITION WAIVER FOR MANAGEMENT and SCUPA.

Employee/Annuitant Verification: I hereby certify that the above named student qualifies as my child/spouse in accordance with, and meets the qualifications as defined by, the APSCUF or SCUPA Collective Bargaining Agreement or the Board of Governors Policy 1984-03-A. I agree to provide to the university proof of relationship and age as may be required. I understand it is my responsibility to meet the deadlines for tuition payment at the university attended by the student.

Employee's Signature (you may sign with your mouse or sign with fingers on a touch screen device) *

clear

DATE * 🛈 +

(Guardian or Beneficiary may provide verification of relationship in the Event of Employee’s/Annuitant’s Death)

UNIVERSITY USE ONLY

HUMAN RESOURCES DEPARTMENT at employing university: The employee’s/annuitant’s eligibility and student’s qualifications for the tuition waiver have been reviewed, and I hereby certify that the information submitted is true and accurate to the best of my knowledge.

_______________________________________________________ _________________

HR Signature Date