West Springfield Education Association
                                       Unit D
                     SICK BANK APPLICATION

Date of application ________________

Name __________________________________________________________________

Address ________________________________________________________________

City_______________________________ State _________ Zip Code ______________

Phone Number ____________________________________

Reason for Request:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Hire date ___________

School ____________________________________ School Phone # _______________

Employee # ____________________________________________________________

WSEA Member since _______MTA Membership # ___________ 

Number of days requested from sick bank _____________________________________

WSEA Medical Form completed Yes __  No __

Date received by President _________________________

Date committee convened __________________________

Approved ___    Denied ___  Reason ____________________________________________

Return to:
West Springfield Education Association
President/Sick Bank Committee
P.O. Box 566
West Springfield, MA 01090
10/8/2017


West Springfield Education Association



Permission Slip to Access West Springfield School Sick Time Information

I give permission to the Sick Bank Committee Chairperson to receive pertinent information from the West Springfield School Department about my initial date of employment, length of employment and the use of my sick time while employed in the West Springfield School System. I give West Springfield School Department permission to release my sick time usage and employment history.

Signature ___________________________________________________
Date _______________________________________
School _____________________________________
Position ____________________________________

I






Return to:
West Springfield Education Association
President/Sick Bank Committee
P.O. Box 566
West Springfield, MA 01090
10/8/2017