________ Full Time SGH Employee

________ Part Time SGH Employee

________ Not Currently Employed by SGH

Home Address

Street _______________________________________________________________

City _____________________________________ State ____________ Zip _______

Telephone: ____________________________ Email :_________________________

Name of School You Plan to Attend: _______________________________________

School Address: _______________________________________________________

Expected Graduation Date: ____________ Expected Program Cost : $ _________ 

Amount you are requesting: $_____________   Date Needed: _________________

Check One:

___ Degree Program Specify: No. Years for Degree Completion: ______

___ Certification Program Specify: No. Years for Degree Completion: ______

___ Non- Degree Program Specify: No. Years for Degree Completion: ______

Attachments:

1.  Briefly explain your educational goal and its benefit to SGH.

2.  Include any information on what you have already done in working toward your goal.

Applications are due the 15th of February, May, August and November. Please send completed application with back-up documentation* to:

SGH Tuition Assistance, Laurie Rockwell, 607 West Main Street, Grangeville, Idaho 83530

Call 983-1700 extension 116 with questions.

* Back-up documentation includes proof of costs associated with funding request and previous term’s grades.

 (For OFFICE Use Only)