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2. 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.

4. First and Last Name*
5. Job Title*
6. Department*
8. Please select one: *

   1. I am enrolling in the Shared Leave (SLB) Bank. I have the required leave hours available (min. 40 combined hours) currently accrued. This may be a combination of PTO and Sick.
   2. I am requesting to cancel membership from the Shared Leave Bank.
   3. I am a member and making an additional donation of sick hours.
   4. I am requesting the use of donated shared leave and have included the required medical certification form completed by my physician.
9. Link to download the form:
   Medical Certification Form
11. How many additional hours are you donating?*
13. Please upload the medical certification form here:*
15. How many hours are you requesting?*
16. Date leave began or is expected to begin:*
18. 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.

    1. I agree.
19. Electronic Signature*
23. Committee Use Only
25. Request Approved or Denied?

    ☐  Approved

    ☐  Denied

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

    ________________________________________________

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

    _______________________________________________________________________________________________________________________________________________________________________________________________

Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

* indicates a required field