Application for Use of Days from Catastrophic Leave Bank 2017-2018
Liberal High School
Eisenhower Middle School
South Middle School
Cottonwood Intermediate School
Sunflower Intermediate School
Garfield Elementary School
Lincoln Elementary School
MacArthur Elementary School
McKinley Elementary School
Praire View Elementary School
Southlawn Elementary School
Washington Elementary School
I wish to apply for _____ days (maximum of 10 days per application, can be half days and full days)
The dates I am requesting are for the following days
Statement of Circumstances (Be specific; non-specific request automatically denied) you must email documentation to
as specified in the current Negotiated Agreement, Catastrophic Leave Bank Rules, Section D, Article 5) Please select one of the following
Major non-elective surgery
Major illness which requires hospitalization and/or convalescence or recuperation in an extended care facility or at home
An accident which requires hospitalization and/or convalescence or recuperation in an extended care facility or at home.
The employee for whom the request is made is participating member of the Catastrophic Leave Bank and is an employee of the district in the following capacity.
Full Time Certified Employee
Part Time Certified Employee
I am aware of the provisions and limitations of the Catastrophic Leave Bank as stated in the agreement.
Send me a copy of my responses.
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This form was created inside of Liberal USD #480.