UMass Tuition Assistance Program Request Form

UMass Tuition Assistance Program Request Form

Note: This application must be submitted no earlier than two (2) weeks before the first day of class and no later than two (2) weeks after the first day of class for the course you are requesting reimbursement for. For example, if your class starts Monday the 15th submit your application between Monday the 1st and Monday the 29th.

You may file a single request form for multiple courses. You will be asked how many courses you are filing for and given the opportunity to provide details for each course.

This form takes approximately 5 minutes to complete.

UMMH Employee ID*

Caregiver Full Name*

Email Address*

Address Line 1*

Address Line 2

City*

State*

Zip Code*

Job Title*

Union/Non-Union Group*

Select

Weekly Scheduled Hours*

Name of Educational Institution*

Degree Type

Select or enter value

Major (if applicable)

Minor (if applicable)

How many courses are you filing for?*

Select or enter value

Course Name 1*

Course Start Date 1*

Course 1 Anticipated Course End Date*

Course 1 Requested Reimbursement Amount*

Course 2 name*

Course 2 Start Date*

Course 2 Anticipated End Date*

Course 2 Requested Reimbursement Amount*

Course 3 Name.*

Course 3 Start Date*

Course 3 Anticipated End Date*

Course 3 Requested Reimbursement Amount*

Course 4 Name.*

Course Start Date4*

Course 4 Anticipated End Date*

Course 4 Requested Reimbursement Amount*

Course 5 Name.*

Course 5 Start Date*

Course 5 Anticipated End Date*

Course 5 Requested Reimbursement Amount*

Course 6 Name.*

Course 6 Start Date*

Course 6 Anticipated End Date*

Course 6 Requested Reimbursement Amount*

Course 7 Name*

Course Start Date7*

Course 7 End Date*

Course 7 Requested Reimbursement Amount*

For Employees hired before 1997 only: Are you using this in conjunction with Remission/Waiver from UMass Medical School?*

Select or enter value

Tuition Assistance Program Form Consent*

I have thoroughly read and agree to all terms and conditions outlined in the Tuition Assistance Program Policy. I both acknowledge and agree my digital signature below represents my compliance with the terms and conditions outlined in said policies.

I agree

Tuition Assistance Program Terms and Agreements*

After the successful completion of coursework and reimbursement or student loan repayment, the employee is required to remain employed (in a staffed, benefited position) with UMass Memorial Health for a period of one (1) year following the date of reimbursement or loan repayment in that calendar year; otherwise, if the employee does not satisfy this one (1) year continued employment, the following shall apply:

Should an employee resign, be discharged from employment for cause or due to poor performance, or transition to per diem employment at employee’s initiation, prior to completing the one-year continued employment condition following receipt of tuition reimbursement or student loan repayment, the employee must repay to UMass Memorial Health the tuition reimbursement previously received upon termination of employment.

I agree

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