Employee Name:

Field is required

Employee ID Number:

Field is required

Daytime Phone Number:

Field is required

Use the format (###) ###-####

Student Name:

Field is required

Student ID Number:

Field is required

Has Student been admitted?

Yes

No

Pending

Field is required

1st quarter waiver for requested:

Field is required

Submission must be made by the 14th day of the quarter requested.

Relationship of Student to Employee

Child

Dependent Partner

Self(Retiree only)

Field is required

Employee Signature

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