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Request to Donate Sick Leave Pool Days

Date:*

Answer Required

Employee Name:*

Answer Required

Address

Street Address:

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City:

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Zip/Postal:

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Telephone:

Number Required

Campus/Department:*

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I am requesting to donate:*

(You may donate a maximum of three (3) days of local leave per school year)

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Name of employee I wish to donate to:*

Answer Required

The sick leave pool shall cease to exist when it has been depleted or when the employee from whom the pool was established, returns to work. Unused sick leave pool days shall revert to the donors in half-day increments divided proportionately according to the amount of contributed by each individual. No general pool shall remain in existence. I certify that the information given on this request to donate for sick leave pool days is accurate and true.

Signature*

Signature Required

Business Use Only

Confirmation Email

Confirmation Email *

Email Required