California State University, San Marcos

Human Resources & Equal Opportunity

Catastrophic Leave Donation Program

Release of Information Agreement

Employee's name _______________________________	Date ______________________
Social Security # ________________________________	Dept. ______________________________

As part of the Catastrophic Leave Donation Program, I request the following regarding the solicitation of donated credits:

[ ]	I hereby agree to allow my name to be released on campus for the purpose of soliciting donated leave credits for my personal injury or illness or that of an incapacitated family member.

[ ]	I request my name be withheld during the solicitation of catastrophic leave credits for my personal illness or injury or that of an incapacitated family member.

[ ]	I request the reason for the catastrophic illness or injury for myself or family member remain confidential.

[ ]	I permit the reason for the catastrophic illness or injury for myself or family member to be released only if it is requested by parties interested in donating credits.

I hereby agree to hold harmless California State University, San Marcos and its employees from any liability concerning all aspects of my request for solicitation of donated leave credits for myself or family member.

___________________________________________________________________________________________

Employee / representative's signature

cc:	Benefits Coordinator
	Employee