Tuition Support

Tuition Support Application

A Program of Smart Support, an equal opportunity employer

and funded by First Things First.

For questions, please contact Amy Zak-Urban

at (602) 200-0434 or email azakurban@swhd.org

2850 N. 24th Street

Phoenix, AZ 85008

Section I: Personal Information

All Fields in yellow are required

Date:

Name:

Address:

City:

State:

Zip:

Phone:

Other Phone:

Master's Degree In:

Master's Degree From School:

EMail Address:

(Phone Ex: 9999999999 No dashes)

Section II: Employment
Are you currently employed:	Yes No	Employer:	Dates Of Employment: From		To:
				Ex:(01/01/2000)		Ex:(01/01/2000)
Have you previously received tuition reimbursement from Smart Support:	Yes No	Month/Year	Ex: (01/2000)

Section III: School, Institution, or Training Center Information
Name of School:
Address:	City:		State:	Zip:
Course Name:	Course Number:		Course Title:	Course Start Date:
Course Time:	Course Meets on:	Mon Tues Wed Thur Fri Sat Sun
Total number of courses requested for reimbursement:
Total cost of course(s)/training event requested for reimbursement: $
If working on a licensure, degree, etc: total courses yet to be earned to complete degree

Section IV: Justification Statement/Essay of Intent
Please describe how the course(s), workshop(s), conference(s) or other training experience for which you are seeking funds will benefit your service to the early childhood mental health field and yourself.

Professional References
Give the names of three persons NOT related to you, whom you have known for at least one year
(Business Associates, Supervisors, Teachers,etc.)
Name	Address	Business	Relationship	Phone Number	Email Address

Reimbursement Agreement

Coursework

I understand that reimbursement for coursework is conditional upon satisfactory course completetion, which is defined as a grade of B or better in an approved course. proof of final grade within 1 month of course completion is required for reimbursement. X (applicant's initials)

Workshops,Conferences,Other Approved Training Events

I understand that if funds are needed for registration they must be requested at least 1 month prior to the deadline for registration. X (applicant's initials)

Certificates of attendance/completion must be provided to the Smart Support Tuition Reimbursement Committee within 1 month of training completion. Recipients of tuition reimbursement who did not attend or successfully complete their training event MUST refund the funds to smart support. X (applicant's initials)

Applicant's Name (by entering your name, you are giving your electronic signature)

Application Date

Residency Agreement

This Tuition Support Residency Commitment Agreement is made by and between and Smart Support. has voluntarily chosen to apply for the Tuition Support program administered by SWHD, to pay for the cost of the applicant's tuition for in the approximate amount of $ .

REQUIREMENTS:

(check each)

I certify that I hold an advanced degree (i.e. master's degree or higher) in [license-eligible mental health disipline] (clinical psychology, counseling psychology, educational psychology,marriage and family therapy, social work, clinical nursing with mental health focus, psychiatry) or am matriculated in a graduate progam leading to an advanced degree in a mental health discipline (indicate one of the above).

I certify that I work in a capacity that includes services to children in the birth to five age range in the state of Arizona. (Applicants who are currently pursuing a graduate degree must intend to focus on or include in their professional activities services to children in the birth to five age range in the state of Arizona).

I certify that I currently reside in Arizona.

I certify that I will receive funds to cover the cost of [intended length of selected program and will maintain residency in Arizona ad service the birth to five populations for SAME AMOUNT OF TIME AS PROGRAMpost-completion of the funded course work. The required period of residency and service will be equal to the length of the coursework.

I certify that I have requested funds to register for coursework, conferences, or other approved professional activities and will deliver proof of satifactory final grade, proof of attendance, and/or copy of certificate of degree. This is a requirement and must be submitted to the Tuition Support Program within 30 days for the full amount of the approved funds.

I certify that if any of the above requirements are NOT fulfilled I will reimburse the Tuition Support Program (SWHD) for 100% of the overall costs of the training or [AWARD AMOUNT.($ ). Provided [Name] fulfills the requirements above for the designated period will have no further repayment obligation to SWHD.

I have received a copy of the agreement for my files.*** Note: you will receive a copy by email when you enter an email address below ***

EXECUTED THIS

SOUTH WEST HUMAN DEVELOPMENT

By:
Applicant:
Title:
Date:

If you would like an email confirmation and a copy of your completed application and residency agreement, enter your email address:

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