2022-2023 STAFF TUITION SCHOLARSHIP PROGRAM HOCKING COLLEGE 
Registrant Information: 
Semester(s) of Enrollment:      Summer 2022            Autumn 2022              Spring 2023 
Current employees and their spouse, children and grandchildren* must complete a scholarship request form each semester. (Form received after the semester is over will not be applied.) 
Name: (Print)____________________________________ Student ID#:______________________________ 
Relationship to Employee/Retiree:    Employee / Retiree        Spouse        Child              Grandchild*
*Grandchildren eligible up to age 23.  If grandchild, please indicate date of birth__________________ 
 Employee Information: 
Name: __________________________________ Employee ID#:_______________________________ Department:______________________________ Position:____________________________________ 
Employment Status:      Permanent      50% or higher Semester Contract       Retiree 
Please Note: Fulltime, regular employees at 50% or above are eligible for Staff Tuition Scholarship Program. 
Adjunct Faculty employees at 50% or above are eligible after two (2) consecutive semester contracts if it appears that the contract will be continued.  Temporary, part-time and student employees are not eligible. 
Information regarding the Educational Benefits Program: 
Learning materials fee and all course fees, fines, and penalties are the responsibility of the registrant. Participants will also be required to pay all other student processing fees charged by the College. Each participant, other than the employee, will be assessed a service fee of $10 per semester. The Tuition Scholarship Program is for Hocking College credit classes only. Courses that require tuition payment to institutions other than Hocking College are not eligible for the scholarship (Example:  COTC, Tri-County, etc.). This program does not cover continuing education courses. 
The employee/registrant’s signature verifies that the individual indicated is a qualified employee or spouse/child/ grandchild and is eligible for the Staff Tuition Scholarship Program. The employee/registrant understands that he/she will be responsible for all fees not covered under the scholarship program and will repay the College for tuition costs should misrepresentation occur.  The employee/ registrant’s signatures also verify the understanding that if the employee contract is not renewed, the tuition scholarship benefit is discontinued 
I understand the terms of this Staff Tuition Scholarship Program and certify that the above information is correct. 
Registrant Signature_______________________________________________ Date_____________________ 
Employee Signature________________________________________________Date_____________________ 
Supervisor Signature_______________________________________________ Date_____________________ 

This Section to be completed by Human Resources 
This is to verify that the employee/registrant identified above is eligible for the Staff Tuition Scholarship Program.
Human Resources Representative Signature               Date Entered into Scholarship Database 
Revised February 2022