CHRISTIAN APPALACHIAN PROJECT, INC

Employee Name: ______________________________________________

Program Name: _________________________________________

Program Number: _________________

Current Sick Leave Balance: ________________________Hours

Number of hour(s) Donated: _______________ Hours (must be in whole-hour increments)

New Sick Leave Balance Total: ___________________ Hours

Employee donated to: ______________________________________________________________________

I understand that this donation is strictly voluntary and is not subject to revocation or retrieval.

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Employee’s Signature                                        Date                        

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Supervisor’s Signature                                       Date

Date Approved _______________________________

 Date Denied _________________________________

If denied, explanation:

__________________________________________________________________________________________

__________________________________________________________________________________________

___________________________________________             

Human Resources Representative                                                

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Date