Winston-Salem/Forsyth County Schools

Exceptional Children Lateral Entry/Provisionally Licensed Teacher

Tuition Reimbursement Application

Name:

(Last) (First)(Middle)

Social Security Number:

School:

Subject Currently Teaching:

I currently hold a Lateral Entry / Provisional (circle one) license in ______.

(License Subject Area)

I am submitting original tuition receipts for coursework that is required to fulfill the conditions of my EC license. I understand that by signing below and submitting this documentation, I am agreeing to continue to teach in my EC license area for Winston-Salem/Forsyth County Schools for TWO years until the 2014-2015 school year or repay the tuition reimbursement amount.

SignatureDate

NOTE: State auditing regulations require that you submit original receipts detailing billing charges by category and indicating that you have made payment. Internet receipts must include your name and the amount of your payment, and an itemized list of charges.

Please return this form to Vicki Lee in Human Resources no later than 4:30 PM on

Thursday, December 20, 2012.

Winston-Salem/Forsyth County Schools

EC Licensed Employees 2012-2013 Tuition Reimbursement Scholarship Application

(for coursework completed between June 2012 and December 2012)

PLEASE TYPE OR PRINTPlease make additional copies as needed.

Name:

LastFirstMiddle/Maiden

School/Location: Social Security #:

Current Assigned Role:

Current Academic Degree and Field:

 BA or BS in  EdS (Cert. Adv. Study) in

 EdD or PhD in  MA, MS, MLS, Med in

Teaching Area(s) on Your Certificate:

Teaching AreaGrade LevelsClass (G, A, Provisional, Lateral Entry)

Teaching Experience:

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

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

 to meet requirements for provisional or lateral entry certification

 to earn additional certification in (certification area)

 to earn degree  MA  MS  Med  MLS  EdS (Cert. of Advanced Study)

in what area of degree

 to earn certificate renewal credit for professional growth

 to expand my understanding/skills in my teaching area

 other (state reason)

Page 2

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

Beginning/EndingTuition

Course Title and NumberCollege or UniversityDates of CoursesCost**

$

$

$

$

**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 AMOUNT DUE!! School or University website with emblem will be considered original if paying on-line.

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

Comments/Recommendation of Your Supervisor:

Signature Date

Scholarship Applicant

Signature Date

Supervisor

Application Deadline:4:30 PM on Thursday, December 20, 2012

Note: Forms received without ORIGINAL RECEIPTS OR CANCELLED CHECKS will be returned and WILL NOT be eligible for further consideration. Internet receipts must include name and social security number and payment made. Forms must be complete with signature and received before the deadline for consideration. Please submit your completed application to Vicki Lee in Human Resources. Telephone: 336-748-4079.