Child Welfare Self-Referral for Stipend Reimbursement

UW-Green Bay Child Welfare Education Program

Attachment D

Self-Referral for Stipend Reimbursement

Stipend Reimbursement: Stipend recipients may voluntarily terminate their contracts at any time by reimbursing the amount of stipend funds received. To do so, submit this form to the Child Welfare Coordinator. Stipend funds must be fully reimbursed within ninety (90) days of the date this form is received. (Please contact the Child Welfare Coordinator if alternative arrangements are necessary)

Please provide your updated contact information:

Name

Mailing Street Address

Apartment Number

City

State

Postal code

Personal Email Address

Telephone Number

Please indicate your reason for voluntary reimbursement:

I am no longer interested in working in child welfare.
I am attending a graduate program and am no longer able to be employed full-time.
I am on FMLA and unable to be employed full-time
Other - Please explain:

Please provide your proposed plan for reimbursement of the stipend funds awarded to you.