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r Completing & Submitting:
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Updated 3/20/20
Employee Name:
(Last)
(First)
(Middle)
Employee ID Number:
Email Address:
Please select the semester/year in which the Tuition Reimbursement is requested:
☐
Fall 20___
☐
Winter 20___
☐
Spring 20___
Summer 20___
I certify that I have met the eligibility requirements and have completed the course(s) taken during the
semester noted above.
Employee Signature
Date
**THE COMPLETED FORM MUST BE FORWARDED TO THE NURSING CLINICAL COORDINATOR &
DEAN’S OFFICE FOR APPROVAL**
NURSING CLINICAL COORDINATOR
☐
Nursing Clinical Instructor has met eligibility requirements.
Approved by:
DEAN’S OFFICE AUTHORIZATION
Approved by:
HUMAN RESOURCE AUTHORIZATION
Approved by:
For Office Use Only - Office of Scholarship & Financial Aid
Processed by:
Nursing Clinical Instructor
Request for
Tuition
Reimbursement/
S
c
h
o
l
ar
ship Authorization
Eligibility
SVSU offers an educational assistance program for Nursing Clinical Instructors. Nursing Clinical Instructors
who: 1) are teaching 40 hours or more in the current semester, 2) are supervising a group of students at a clinical
site, and 3) have completed a Memorandum of Appointment – Clinical Instructor (Agreement) for
the following semester, are eligible for reimbursement of 50% of tuition and course-related fees for SVSU
courses taken during that semester. Reimbursement is limited to $5,250 per calendar year. Eligible Nursing
Clinical Instructors will be required to pay the tuition and fees by the posted due date. At the completion of the
semester, they will receive a refund of the eligible amount when the request for reimbursement is submitted.
PLEASE NOTE: Nursing Clinical Instructors who only teach in the simulation lab are NOT eligible for
the tuition discount. Spouse & Children of Nursing Clinical Instructors are also NOT eligible for the
tuition waiver.
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Completed 1 February 2021

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