Southern Columbia Area

SOUTHERN COLUMBIA AREA EXCELLENCE AND PRIDE

GRADUATE COURSE APPROVAL/CREDIT REIMBURSEMENT REQUEST

NAME: ______DATE: ______ADDRESS: ______PHONE: ______PRESENT AREA OF ASSIGNMENT:______GRADUATE CREDITS COMPLETED TO DATE (including IU credits): ______GRADUATE LEVEL COURSE NAME: ______GRADUATE LEVEL COURSE NUMBER: ______COLLEGE OR UNIVERSITY: ______CREDITS TO BE EARNED: ______DATES OF REQUESTED COURSE: (Begin) ______(End)______BRIEF DESCRIPTION OF COURSE WORK: ______BASE TUITION EXCLUDING FEES (Attach proof of cost) $______

APPROVED: ______

REJECTED: ______

______Signature Superintendent’s Approval Date Approved

Upon completion of the graduate course(s), an official transcript must be provided to the District Office within 60 days following course(s) completion. Please note you must attain a grade of “A” or “B” (or equivalent in a non-graded course) to be eligible for tuition reimbursement. If you do not, any pre-reimbursement must be repaid to the district.

PRE-REIMBURSEMENT REQUESTED ( i f yes)

FOR DISTRICT OFFICE USE ONLY

Official Transcript Received: ______

Annual Allocation Amount: ______

Reimbursement Received This Academic Year: ______

Amount Requested: ______

Amount Approved: ______

Budget Account Code: 11240. ______

______Superintendent’s Approval For Payment QUALITY EDUCATION FOR EVERY CHILD gradcrse.frm (rev. 7/03)