LOUDOUN COUNTY PUBLIC SCHOOLS
DONATED LEAVE RECIPIENT APPLICATION
ANYONE INTERESTED IN QUALIFYING AS A “DONATED LEAVE RECIPIENT” MUST SUBMIT THE
COMPLETED FORM AND REQUIRED DOCUMENTATION TO RETIREMENT & DISABILITY PROGRAMS.
INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED.
Name:
Date of Birth:
PID:
Phone:
State:
ZIP Code:
Current address:
City:
EMPLOYMENT INFORMATION
Current Position:
Current Location:
Phone:
E-mail:
@lcps.org
Supervisor:
IF APPLICABLE, PLEASE PROVIDE THE NAME OF YOUR AUTHORIZED PERSONAL REPRESENTATIVE:
Authorized Personal Representative:
Address of Representative:
City:
State:
Zip:
Home Phone and Email address of the Legally Authorized Personal Representative:
A COMPLETE LEAVE RECIPIENT APPLICATION PACKET INCLUDES:
 This form, and
 Medical certification from a health care provider regarding your health condition and need for leave with
respect to the health condition, and
 A signed agreement to release a request for donation to LCPS employees.
SIGNATURE
I certify that all statements and data provided are true and correct to the best of my knowledge. I have read the
Donated Leave Program regulations and procedures and understand and accept the conditions therein. I acknowledge
that the Donated Leave Program is provided as a benefit to eligible employees and that participation in the program as
either a leave recipient or leave donor is strictly voluntary. I understand that acceptance of donated leave signifies
agreement to the terms and conditions of this policy and its accompanying regulations including, but not limited to,
submission of requested medical documents and required monitoring activities.
Signature of applicant:
Date:
Signature of Personal Representative (if applicable)
Date: