Emergency Leave Request

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After completing and submitting this form it will be reviewed by the superintendent and KEA president for a decision. As per the negotiated agreement the decision is not subject to grievance or appeal.

Name *

Date submitting request *

YYYY

I request the use of the Emergency Leave Bank for *

myself

my child

my spouse

my parent

my sibling

I have chosen to use the Emergency Leave Bank and (choose one) *

therefore will not be applying for short term disability

may need long term disability

Number of days you are requesting to be deducted from the Emergency Leave Bank and credited to your individual leave account. *

Please detail the reason for your request (be explicit). A doctors statement may be necessary upon request. *

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