HENRY FORD HEALTH SYSTEM 2015 Nurse Tuition Funding Program Application Application Due September 14, 2015 PLEASE PRINT CLEARLY. (Last) (First) (M.I.

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1 HENRY FORD HEALTH SYSTEM 2015 Nurse Tuition Funding Program Application PLEASE PRINT CLEARLY PERSONAL DATA: Name Address (Last) (First) (M.I.) (Street) HFHS Address (City) (State) (Zip Code) Telephone Number (Home/Cell) Present Occupation/Job Title Work Phone Current work area (unit/clinic/hospital) Manager/Supervisor Name (please print) Employee ID# CRITERIA: Degree Pursuing (place an X in the appropriate box): Associate Degree in Nursing BSN Completion Bachelor of Science in Nursing Master of Science in Nursing College you are attending: Expected graduation date: 1. Full Time at HFHS. Yes No, hours per week 2. Minimum of one year of service at HFHS. Yes Dates: 3. Include a Letter of acceptance into an accredited program. 4. Have your received any other loans from HFHS? Yes No If yes, please explain: 5. Include one typewritten page (double spaced) indicating educational and career goals upon attainment of this degree. Explain why the attainment of this degree will facilitate your professional development. 6. Include your Curriculum Vitae including the following: educational background, professional experience, honors and awards, activity in professional and community organizations. I declare that the information contained in the Application is correct and complete. (Signature) (Date)

2 (Employee Name) HENRY FORD HEALTH SYSTEM 2015 Nurse Tuition Funding Program Application MANAGER APPROVAL TO PARTICIPATE is applying to participate in the Nurse Tuition Funding Program, to begin in September 2015, to assist the employee in attaining a/an degree. YES NO Has completed one year of employment at HFHS. Has a satisfactory performance evaluation and attendance record. If no, please explain and provide documentation. Has a valid State of Michigan RN license (if applicable). Is a Full Time Employee If no please state hours/week Yes, I approve of (Employee Name) Nurse Tuition Funding Program. participating in the No, I do not approve of Nurse Tuition Funding Program. (Employee Name) participating in the Manager Name/Signature Date Print Name/Signature Director/Administrator/CNO Name/Signature Date Print Name/Signature

3 HENRY FORD HEALTH SYSTEM 2015 Nurse Tuition Funding Program The Nurse Tuition Funding Program (NTFP) is designed to assist HFHS employees in obtaining a nursing degree to advance their skills and expertise in contemporary practice. This is a loan program for tuition and fees related to an educational program in exchange for a designated length of employment with Henry Ford Health System (HFHS). Maximum Amount The number of, and monetary amount will be determined each year in conjunction with budget planning. The NTFP will support the following degrees from accredited nursing programs*: Associate Degree in Nursing (complete within 4 years) Bachelor of Science in Nursing (complete within 5 years) BSN Completion (complete within 5 years) Master s of Science in Nursing (complete within 5 years) *The program must meet the American Nurses Credentialing Center (ANCC) eligibility requirements for certification in the area of specialty. CRNA and DNP programs are not funded through the Nurse Tuition Funding Program. Please note that some out of state on-line programs do not meet the ANCC requirements for certification. Eligibility You must be: A current Full Time HFHS employee and remain Full Time during this program Currently enrolled in an accredited nursing program* that will result in the degree within the specified time frames Completion of one year employment at HFHS Current satisfactory performance evaluation Valid RN license in the state of MI (RNs enrolled in BSN completion or MSN programs) Remain in good standing at HFHS (no disciplinary actions, including attendance) Maintain the minimum GPA specified by the nursing program If you received a loan from HFHS, it must be 66% forgiven at the time you apply for this program. Application Process A completed application consists of the following components, typewritten and submitted together. All applications must be complete to be considered for selection: Complete Application Form. A copy of your most recent performance evaluation (front page only). A copy of RN license in the State of MI (RNs enrolled in BSN completion or MSN program). A copy of your letter of acceptance into an accredited program. One typewritten page (double spaced) indicating educational and career goals upon attainment of this degree. Explain why the attainment of this degree will facilitate your professional development. Curriculum Vitae including the following: educational background, professional experience, honors and awards, activity in professional and community organizations.

4 LOAN ADMINISTRATION PROCESS - Deadline for submission for 2015 is September 14, I. APPLICATION Applicant must submit a completed application; incomplete applications will not be considered. Applications may be accessed on-line via HR Connect and click on Nurse Tuition Funding Program Submit completed packet by September 14, 2015 to: Henry Ford Health System, Nursing Development & Research, One Ford Place, Suite 2B, Detroit, MI Note: Faxed copies will NOT be accepted. Employees do not need to reapply each year once accepted for the NTFP. Employees need to submit proof of continuation in a nursing program to maintain acceptance in the NTFP. Employees need to submit documentation of employment status each time funds are requested. Employees must reapply if they change the school or program they were accepted for in the NTFP. Employees may request, in writing, to reduce work hours for one semester while in the NTFP. II. APPROVAL NDR will notify manager and employee of acceptance status into the Nurse Tuition Funding Program by October 5, NDR will request employee signature on loan agreement by October 19, The loan forgiveness will begin on September 1, 2015, if the tuition reimbursement benefit is completely exhausted for that calendar year. If the cost of the course exceeds the tuition reimbursement benefit remaining, the loan forgiveness will be initiated to cover the difference. A designated number of loans will be approved in each program category. III. DISTRIBUTION OF FUNDS Funds will be distributed directly to the student upon successful completion of each semester. A grade of "C" or better is required for undergraduate studies and a grade of "B" or better is required for graduate studies in order to receive reimbursement. A "Pass" grade is required when a Pass/Fail system is utilized. Upon exhausting system tuition reimbursement, the employee will submit the following to NDR: Copy of semester grades Copy of tuition reimbursement form showing exhaustion of benefit for the calendar year Copy of tuition receipt/bill from school Copy of proof of payment for tuition & fees. Books are not covered (cancelled check, billing statement) Signed sheet by Nurse Manager A copy of each semester grades and tuition receipt must be submitted within 45 days after completion of each semester. A promissory note will be signed by the employee prior to distribution of each loan after successful completion of the semester. The loan agreement will be considered valid when signed by both the employee and designated HFHS representative.

5 Nurse Tuition Funding Program 2015 Appendix A PROGRAM AMOUNT EMPLOYMENT COMMITMENT Employees use entire tuition reimbursement benefit ($3,000/year full time) first and must receive approval from manager in order for application to be considered. Employees must maintain FT employment while in school. You must notify the NTFP if you change your employment status while in this program i.e. full time to part time. This may impact your eligibility for the program. a) A.D. Nursing Program Up to $8,000 tuition loan 36 mo. FT RN after passing NCLEX b) B.S.N. Traditional Program Up to $14,000 tuition loan 36 mo. FT RN after passing NCLEX c) B.S.N. Completion Program Up to $14,000 tuition loan 36 mo. FT RN after obtaining degree d) M.S.N. Program Up to $14,000 tuition loan 36 mo. FT RN after obtaining degree HFHS MUST APPROVE THE EDUCATIONAL PROGRAM IN ORDER TO BE ELIGIBLE FOR THE NURSE TUITION FUNDING PROGRAM