Employer-Provided Tuition Assistance Release of Grades to Employer

Student Information

First Name

Last Name

Email Address

Birthdate

Student ID #

Enrollment and Permission Information

Effective Entry Term

I authorize Kentucky Wesleyan College to release my grade report to my below listed employer for payment to process from the employer to Kentucky Wesleyan College. I understand that my balance will be held until payment is received by the cashier of Kentucky Wesleyan College and I am financially responsible for ensuring timely payment on the balance of my account. The terms and conditions of my benefit structure are attached to this release. I understand that I am able to do this on my own, but have given authorization for this release.

Employer/Company Name

Employer City

Employer State

Employer Contact Name

Employer Phone

Employer Email

Acknowledgments

I acknowledge that this form will be in effect during my continued enrollment at Kentucky Wesleyan College. To cancel this authorization, I understand I must notify the Registrar's Office via email at registrar@kwc.edu and the Financial Aid Office via email at finaid@kwc.edu. By typing my name below, I authorize its use as my digital signature.

Signature