Request Form For Leave

LEAVE REQUEST FORM

(The following request is to be completed and returned to the Human Resource Office)

"*" indicates required fields

Today's Date:*

Employee's Name:*

First Name Last Name

Employee's Location*

Position*

I request a leave of absence from:*

I request a leave of absence to:*

for the following reason:

For birth of my child and/or to care for the newborn child.

For placement of a child with me for adoption or foster care.

To care for my spouse, child or parent with a serious health condition.

Military FMLA leave

Own serious health condition makes me unable to perform one of the essential functions of my job.

Educational Leave

Other

I request to use:

Paid Vacation Days

Personal Days Hours

check all that apply

Location during leave

Phone number to reach me during my leave

Employee's Signature

Approved By Signature

Date*