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Senior Citizen Tuition Assistance Agreement Form


Name
   
Former Name (if different):
     
Account
EMPLID:
Last 4 digits of SSN:
Date of birth:
Address


     
Telephone
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Cel  


  • A. To be eligible for free tuition and fees and receive academic credit , a person must meet the following criteria:
    1. Be 60 years of age or older
    2. Be domiciled in Virginia for a minimum of a one-year period prior to the beginning of classes for the semester/term for which one seeks assistance
    3. Be admitted to the college as a student
    4. Had a taxable individual income not exceeding $23,850 for Virginia Income Taxes for the year preceding the semester of enrollment.
    5. Be admitted to a course(s) after tuition paying students have been accommodated. Enrollment for credit courses will be the first official day of the class.
  • B. To be eligible for free tuition and fees to audit credit courses or to enroll in non-credit courses, a person must meet the following criteria:
    1. Be 60 years of age or older
    2. Be domiciled in Virginia for a minimum of a one-year period prior to the beginning of classes for the semester/term for which one seeks assistance.
    3. Be admitted to the college as a student

(Please click or tap only one option)
A. I hereby certify that I am qualified for free tuition for credit classes under the Senior Citizens Higher Education Act, as amended. (Copy of federal taxes required).

Directions: Send your registration card or an email of desired courses as well as proof of taxable income (i.e., most current taxes, non-filer from, social security statement) to the Office of the Registrar. Megan Walker, mwalker@patrickhenry.edu, 276-656-5481


B. I hereby certify that I am qualified for free tuition for audit of credit classes or for taking non-credit classes under the Senior Citizens Higher Education Act, as amended.

Directions: Send your registration card or an email of desired courses to the Office of the Registrar. Megan Walker, mwalker@patrickhenry.edu, 276-656-5481
Sign the line above with Mouse or Finger