PUBLIC HIGHER EDUCATION FEE DISCOUNT
FOR CHILDREN OF LICENSED PUBLIC SCHOOL TEACHERS
AND CHILDREN OF STATE EMPLOYEES
Higher Education Institution:
Term: Fall Spring Summer Other Year:
STUDENT INFORMATION
Full Name of Student: Student ID No.:
Date of Birth:
Address: City, State, Zip Code:
Relationship to Employee:
Natural or Legally Adopted Child
Employee’s Stepchild Living with Employee in a Parent/Child Relationship
Other Individual Living in a Parent/Child Relationship with the Employee
Explain:
TEACHER/EMPLOYEE INFORMATION
(If currently employed, must be employed full-time.)
Employment Status (check one): Licensed Public School Teacher Public High School Technology Coordinator
State Employee Retired State Employee Deceased State Employee
Phone No.:
City, State, Zip Code:
Full Name:
Edison ID (State) or Employee ID No.:
Address: _________________________________________
Employer:
Phone No.:
TEACHERS ONLY (if applying as a public school teacher, you must be licensed by the Tennessee Department of Education and provide your
current license number in the space below.)
Current License Number:
We individually do hereby certify, under penalties of perjury, that all of the information contained above is true, correct, and complete
to the best of our knowledge, that we hereby acknowledge receipt of a copy of the rules of this fee discount program, and that to the full
extent of our knowledge and information both the “employee” and the “student” are fully qualified for this fee discount under the rules.
If following enrollment the student is found to be ineligible for this benefit, the student will be responsible for payment of all waived
fees plus any other applicable charges.
Employee Signature Employer/Division of Retirement Signature Student Signature
Date Title Date
Date
FOR INSTITUTIONAL USE
Tuition Amount: $ Discount: $
Accepted By: Date:
HE0007
Retired Public School Teacher
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