Application for Tuition Exchange & ELCA Scholarship
Dependent Child of Employee
Submit this form and Proof of Relationship*
Please complete entire form and return to the HR Department. Incomplete forms will not be accepted.
DEPENDENT STUDENT (CHILD) INFORMATION
LAST FOUR DIGITS OF SOCIAL SECURITY #
PERMANENT HOME ADDRESS – STREET
*Acceptable proof of relationship includes birth certificate and parental Tax Returns (must list the dependent as an exemption to qualify)
For additional reference please refer to the Employee Handbook.
PLEASE INDICATE WHICH ACADEMIC YEAR AND BENEFIT THIS APPLICATION IS FOR
NUMBER OF SCHOOLS APPLIED TO:
The Tuition Exchange (TE) Scholarship (tuitionexchange.org)
ELCA Tuition Exchange Scholarship (http://www.elca.org/Our-Work/Leadership/Colleges-and-Universities)
LIST INSTITUTIONS WHERE DEPENDENT IS APPLYING TO OR ATTENDING. (You may add to or delete from this list after the application is submitted).
NAME OF SCHOOL AND CITY/STATE
NAME OF SCHOOL AND CITY/STATE
PLEASE CONFIRM STATUS FOR ACADEMIC YEAR REQUESTED ABOVE:
FEDERAL PELL GRANT ELIGIBLE:
EMPLOYEE (PARENT) INFORMATION
EMPLOYEE’S DEPARTMENT / WORK EXTENSION
To the best of my knowledge, I certify that the above information is true and correct.
I have attached or have on file with Human Resources proof of relationship, including a copy of the Tax Return for parent of dependent child.
SIGNATURE OF DEPENDENT STUDENT (CHILD)
SIGNATURE OF EMPLOYEE (PARENT)
AVP of Human Resources Signature
Human Resources Department - 60 W Olsen Road #1100 - Thousand Oaks, CA 91360 - P: 805.493.3185 – F: 805.493.3655 Oct 2013
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