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LOURDES HEALTH SYSTEM
APPLICATION FOR EDUCATIONAL ASSISTANCE/TUITION REIMBURSEMENT
INSTRUCTIONS:
1.
Fully completed the “Application for Educational Assistance/Tuition Reimbursement” form below which requires:

Completion of all of the fields on the form

Associate’s signature

Leader’s signature
2.
Include a Registration document which clearly identifies school by name or logo and lists:

Student name

Course title including the course number of each class

Number of credits for each course

Duration of the semester or beginning and ending date of the course(s)
3.
Include Student Invoice which clearly identifies:

Student name

Per credit cost of tuition or tuition cost for each course “must be marked tuition”
4.
Grades – Full cost and post payment only

Must include student’s name
5.
Send completed application and required documentation to Human Resources in Camden or fax to 856-757-3044. If you have
questions about this policy please contact the Human Resources office 856-757-3838.
Forms that are incomplete or incorrect AND do not include the supporting documentation indicated above, will be returned.
Name__________________________________________ Dept_______________________________ Daytime Phone #____________________________
Email address ________________________________________________________________________
Do you anticipate taking a leave of absence
while taking this course(s)? Y  N 
Position_______________________________________ Employee ID #___________________________
Cost of Tuition Per Credit $_____________
(Excluding Fees)
Date of Hire_____________________________
FT  PT

Weekly Budgeted Hours________
REV 7/2012
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LOURDES HEALTH SYSTEM
APPLICATION FOR EDUCATIONAL ASSISTANCE/TUITION REIMBURSEMENT
Associate Name_________________________________
Name of School_________________________________Degree/Major________________________________________________________________________
Type of Payment: (please check one)
Pre-payment  Post-payment  Full Cost 
(Nursing/
Credits
Course
Begins
Course
Ends
1._________________________________________
____
_________
_________
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


2._________________________________________
____
_________
_________




_________
_________




Course Name
3._________________________________________
____
Lourdes Wellness)
Graduate
Undergraduate
Certification
LIP (IDP)
as in Success Factors™
Leader Agreement: I acknowledge that I have read Policy AS0540PER, Educational Assistance (Tuition Reimbursement) Program, and with my
signature, I confirm that this request is in accordance with the requirements set forth in this policy including all of the necessary documentation
required to process for payment.
Leader Signature ____________________________________Date _________________
Associate Agreement: 1. I acknowledge that OLLHCS, Inc.’s tuition assistance is being made on the condition that my employment is not
terminated or that my status does not change to per diem for one year following completion of the last course for which I am reimbursed. I agree to
return to OLLHCS, Inc. all tuition granted to me within one year prior to my termination or status change date. If I applied for prepayments and
during the course for which I received payment, I withdrew or did not satisfactorily complete the course, I must refund OLLHCS, Inc. the entire
amount of educational assistance money received for that course. 2. I certify that I have/will disclose to OLLHCS, Inc. any amount of funding
received from other source, i.e., Federal Education Assistance, Veteran’s Administration, Scholarship, or Student Grant to pay for the course(s)
above, if applicable, so OLLHCS, Inc. reimbursement will not exceed 100% of course cost 3. I understand that educational assistance may be
subject to State and Federal taxation and will be included with regular paycheck. 4. I understand that I cannot receive additional educations
reimbursement funds for future courses until I have successfully completed and submitted grades for the courses listed on this form.
Associate Signature ____________________________________Date _________________