Pittsylvania County Schools by FB80043

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									                                                             Pittsylvania County Schools
                             Application for EISENHOWER Funding (Title II, Part A)                                                                       JULY 2012
                                                               for College Credit Course
        Applicant must complete this form and submit it for approval to the Assistant Superintendent for Administration PRIOR TO REGISTRATION.
             A COPY WILL BE RETURNED AND MUST BE SUBMITTED TO THE REGISTRAR WHEN REGISTERING FOR THE COURSE.


                                           QUALIFYING AREAS OF INSTRUCTION (Federal Core Content)
          Priority approval will be given to the following: Provisional Licensure, Renewal of Licensure, Add-on Endorsements in Needed Areas (Science & Math)
                     Only courses in the federal core content areas as noted below will be considered as allowable under Title II, Part A tuition funding.
Science                          History                            Geography                            English                                Art
Math                             Civics                             Government                           Reading                                Foreign Language
Economics                                                                                                Language Arts                          Music

                     If funding is available, amount will be approved for one course at 100% up to $500 per semester.
                                                                       PLEASE PRINT OR TYPE

Name in Full

Social Security #                                                                               School

Address
                              Street or P.O. Box                                                                        City                     State             Zip Code

Position                                                                                 Current Assignment

License Held                                                                                   License Expires        June 30,

Endorsements                                                                  Have you applied for Tuition Assistance from Human Resources?

I will attend
                              Name and address of College or University
I shall take the
following course:
                              Course No. & Exact Title                                                                                       Credit Hours (sem/qtr.)

Date(s) of Attendance ______________________________________________                                          *Tuition Cost for Course $ _________________

Semester: (Place an X in the appropriate box)                   Summer                                        Fall                                Spring

I am enrolling in this course for the reason(s) checked below:
            To meet the requirements for a provisional license, to become highly qualified or an endorsement in a federal core content area in which I
             have been assigned. Specify type of license or endorsement required: _______________________________________________________
            To renew my license with the same endorsement(s). (Renewal date within one year)
 I agree to repay the School Board any tuition assistance I received if I withdraw or fail to receive a passing grade from the course mentioned above.
 Mandatory fees and/or course fees are the responsibility of the student. Items excluded from tuition assistance funding are books, e-books, registration fees,
  comprehensive fees, student activity fees, resource fees, online fees and capital outlay fees. These fees should be paid before registering of classes.
 I understand that it is my responsibility to notify Monica Glass at the School Board Office prior to the registration date if I cannot take or do not successfully
  complete the class.

Applicant’s Signature                                                                                                Date ____________________________

                                   (This form must be approved and provided to the college at the time of registration.)


                       TO BE COMPLETED BY THE ASSISTANT SUPERINTENDENT FOR ADMINISTRATION
____       Request for funding is approved in the amount of $ ____________ for the course above.
____       Request for funding is denied. Reason(s) listed below.
            Funding is limited to federal core content areas classes and provisional licensure requirements.
            Course is not in endorsement area.                                  License renewal date is not within a one year period.
            Funding is depleted for the current fiscal year.                    Other _____________________________________

The Pittsylvania County School Board may pay the above amount directly to the college upon certification from the college that the
student has enrolled in the course. This certification should be mailed to:

   Dr. Lillian D. Holland
   Assistant Superintendent for Administration                                 _____________________________________________________
   Pittsylvania County Schools                                                 Dr. Lillian D. Holland, Assistant Superintendent for Administration
   P. O. Box 232
   Chatham, VA 24531                                                           Date _________________________________________________

								
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