Name *

First Name

Last Name

Phone *

(###)

###

####

Days or Hours *

Days

Hours

Beginning On *

Select the start date

MM

DD

YYYY

Ending On *

Select the end date

MM

DD

YYYY

Return To Work *

Select when are you returning to work

MM

DD

YYYY

Reason For Request *

Personal Leave - No Coverage

Personal Leave - With Coverage (write staff name in the "Other" section)

Paid Vacation (write total hours paid in the "Other" section below)

Funeral / Bereavement

Jury Duty

Family Reason

Medical Leave (please submit Doctor's note)

To Vote

Other - Write message below