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Sick Leave Bank Donation Program

  1. Shared Leave Bank Donation Program

    The Employee Handbook (Section 10.19) authorizes a shared leave donation program for eligible full time city employees. An initial donation of sixteen (16) hours, or twenty-four (24) hours for fire, is required to establish membership in the pool. A member must have a minimum of forty (40) hours of combined sick leave and PTO remaining after their initial donation at the time of enrollment.

    This is a voluntary benefit; however, you must be a member of the pool to qualify to receive any donated shared leave time. Donated shared leave is granted only with approved medical certification for the employee or a member of their immediate family’s catastrophic medical condition. Immediate family is defined on page six (6) of the Employee Handbook.

    After the initial enrollment, employees who are not currently members of the pool and who meet the requirements, will be given the opportunity to enroll annually during the open enrollment period. Employees may also request in writing to cancel membership from the pool during open enrollment.

    By signing below, I wish to participate in the City of La Vergne Shared Leave Program. I acknowledge that I must donate sixteen (16) hours of sick leave or twenty-four (24) hours for fire, and must have a minimum of forty (40) hours of combined sick and PTO leave after the initial donation.

  2. Please select one: *
  3. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon your to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  4. Committee Use Only
  5. Request Approved or Denied?



  6. If approved, date donated leave usage will begin:


  7. If denied, committee’s reason for denial:


  8. Leave This Blank:

  9. This field is not part of the form submission.