Haysville West Middle School

Name______________________________________Building_________________

First

MI

Last

Outcome of the application will be sent via email:

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(your email address

–

please print neatly)

By making this application, I confirm that I am an active participate in the Sick

Leave Bank according to the guidelines in Article VIII, Paragraph 5 of the Haysville

USD 261 Negotiated Agreement, and that my individual Sick Leave has been

exhausted./ I acknowledge that applying to the SLB does not automatically mean

days will be granted.

_______________________________________________________________

Signature of applicant Date

Denial of an application for days from the Sick Leave Bank (SLB) may be appealed

by submitting a letter to the chairperson of the SLB.

Please provide a brief explanation for the use of the day(s) requesting from the

Sick Leave Bank. Please attach a copy of a doctor’s statement relating to these

days, if applicable.

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

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Number of Days Requested___________

Sick Leave Bank committee retains the right to request further information .