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Volunteer Leave Request Form

  1. Volunteer Leave of Absence Request
    A leave of absence may be for personal reasons or medical necessity. A member, in good standing for one (1) year, shall be allowed to apply for a three (3) month personal leave of absence in writing to the Chief. The Chief shall approve or deny all leave of absences. A personal leave of absence reuest for a period longer tha three (3) months will require an interview with the Chief regarding the requested leave. The maximum allowable personal leave of absence will be six (6) months. Upon approval of a personal leave of absence longer than thre (3) months, the member must return all issued JH Fire/EMS items/equipment, as assigned, to Admin and a letter will be filed in the member's personnel file. The volunteer agrees to return to duty within or by the end of time designated. For complete details on the process for a member to take and return from a leave of absence, please see policy 5-2. An approved leave of absence does not affect the volunteer's date of employment for benefit calculations. However, the department will cease to pay for a member's Fire/EMS volunteer pension and Transamerica policy for the duration of a personal leave of absence. The volunteer will be responsible for reimbursement to the department for their Fire/EMS volunteer pension and Transamerica premiums within thirty (30) calendar days after going on a personal leave of absence. Fire/EMS pension and/or Transamerica policy will be cancelled if not paid in the time required. Please note that a volunteer approved for a medical leave of absence will be excused from paying their Fire/EMS volunteer pension or Transamerica policy. A volunteer is also required to contact their station leadership as soon as their leave of absence is approved in order to address any potential problems with the completion of their departmental task book. If the volunteer decides not to return to the department, he/she shall notify the Chief in writing immediately. Ailure to report at the expiration of a leave of absence shall be considered a resignation.
  2. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  3. Equipment Returned to Admin
  4. Pension and Transamerica Policy Paid
  5. Leave This Blank:

  6. This field is not part of the form submission.