Application for Medical Leave

Medical Leave Request

When clergy who are members of an annual conference (¶ 369) are unable to perform their ministerial duties because of medical and disabling conditions, upon recommendations of the conference Board of Ordained Ministry and the conference board of pensions, and by a majority vote of the executive session of clergy members in full connection with the annual conference who are present and voting.
The completion of this application is the beginning of the process of working with the Board of Ordained Ministry and the Conference Board of Pensions. The completion of this application does not qualify you will be approved for leave, there are many more steps, forms, and documentation that is required before one can qualify for medical leave.
Name

First NameMiddle NameLast NameSuffix
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@ngumc.net
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Conference Membership
Where are you currently appointed?
District where your appointment is located?
Is your District Superintendent aware that you are applying for disability/incapacity leave?
Are you requesting a change ad interim (immediately or give a date) or at the next session of Annual Conference (7/1)?
Please describe the circumstances that necessitate your requesting a change in your status at this time.
Have there been any disruptions or problems in your current appointment preceding this request, and, if so, did your SPRC chair or committee or equivalent meet with you? If you did meet, please describe the nature of the meeting and conversation.
In your opinion, what are the specific criteria or goals that you see need to be met before ending your leave?
Please use the space below to write anything you feel the Board of Ordained Ministry should know about you, your life, or your ministry:
Please attach any documentation or materials needed to support your request.

Browse Files

Cancelof
You will need to stay in contact with your district superintendent, and remain connected to your current appointment until your application is approved. After approval you must maintain a relationship with a local church.

By clicking the submit button below, you are providing a confirmation that the information you have given is correct and that you are electronically signing this request for consideration for disability/incapacity leave.
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Medical Leave Request