(Please type or print in black ink.)
This policy is a revision of one first approved in 1984 for teachers enrolled in courses for re-certification. The policy now includes teachers, counselors, administrators, and supervisors who teach Kindergarten through grade 12 in private or public schools in the Commonwealth of Virginia. Courses may be taken for re-certification or in pursuit of a degree. The following eligibility guidelines apply:
  1. Kindergarten through grade 12 public and private school teachers, counselors, administrators, supervisors, librarians, coaches, and other support staff are eligible.
  2. Eligible personnel must be contractual employees of a public school division or private school within the Commonwealth of Virginia.
  3. Individuals on official leave from their assignments are eligible for reduced tuition.
  4. There is no restriction on the number of hours that can be taken.
  5. Courses for which educators request reduced tuition must be for professional development, not for planned career changes outside of education.

Name:  ______________________________________
Social Security No:  ______________________________________
Address:  ____________________________________________________________________________
Home Telephone:  ______________________________________
Semester Enrolled:  _______________________________________
Course(s):  ______________________________________
Campus Location:      Online       Blacksburg       Northern VA Graduate Center       Roanoke Graduate Center 
Other (list location):  ____________________________________________________________________________
I hereby certify that the above named is (employed/on official leave) in the State of Virginia as (circle one)
Teacher    Counselor    Adminstrator    Supervisor    Other ________________________
School system currently employed by. (Please do not abbreviate.)
Signature of the Principal or Chief Administrative Officer
Date and Telephone Number
Please return this form with your registration form or to the registrar at your local academic center by the second class meeting. Failure to submit this form in a timely fashion will result in your being billed for the regular applicable tuition charges.
The Honor System
I certify that all information given on this application is true and correct. I will abide by all rules and regulations of the University. I will accept the responsibility of the Honor Code of the University. I pledge I will not lie or cheat. I understand that violation of the Honor Code may result in severe penalties including dismissal from the University.
Student's Signature