SUPERVISING & RESOURCE TEACHER
TUITION WAIVER PROGRAM
(Maximum of 12 hours per academic year)
Date:							For use at :  Eastern Kentucky University
Full Name							Social Security Number
Mailing Address				City		St	Zip		Phone Number
School District				School					Phone Number
This section to be completed by Principal.
I hereby certify the above employee has completed supervision of a student teacher.
		8 Week			16 Week			Principal's Signature
I hereby certify the above employee has completed an assignment as a KTIP Resource Teacher.
								Principal's Signature
Indicate the term and year for which this waiver is to be used for:						___ Fall	___ Spring	___Summer	Year
Indicate the total number of tuition credit hours to be utilized for the term listed above:
Name of student/intern supervised and the name of the institution.
						Student/Intern Name			Institution Attending
Proposed Class Schedule *
Dept.	Course and		Course Title						Semester	Time	Days
	Section Number		(This does not replace the class registration process)
Total number of class credit(s) to be used at the listed institution:
*Enrollment in the course(s) listed above is subject to space availability.  "A postsecondary institution shall not be required
to establish a course to meet teacher request."  (Per KRS Chapter 156, Section 9)
DEADLINE DATES FOR PROCESSING
Must submit form by the last day of regular registration*see class schedule book
RETURN FORM TO:				Scholarship Office
				c/o Amanda McCracken
				SSB  CPO 56
				521 Lancaster Avenue
				Richmond KY  40475-3156
				Phone:  859-622-8032			Fax:  859-622-8479
Anyone using this form in a fraudulent manner is subject to dismissal from the credit granting institution and any legal
implications that may apply to fraudulent use.  If a person takes classes at more than one institution in one semester, a
Statutory Tuition Waiver must be completed for each institution attended.
Once this waiver form has been completed, the student is responsible for completing all necessary processes at Eastern
Kentucky University.
1.  Admission to the institution must be achieved.
2.  Verify acceptance into your program of study, if applicable.
3.  Have your class schedule approved and registered at the institution.
(Schedule must be processed each semester of attendance.)
4.  Submit this waiver form to the Scholarship Office at Eastern Kentucky University.
(This form must be completed and submitted to the institution each semester classes are taken.)
5.  Classes are subject to availability each semester, and the student is subject to all regulations
at the institution.
REMINDERS:
* Graduate courses are taxable
benefits, which the student is
responsible to report.
* Each student must be in good
academic & financial standing at
Eastern Kentucky University
* Timely submission of information
allows for better processing of the
waiver