Leave of Absence Inquiry
Your name
Your name
*
First
Last
Your phone number
Your phone number
*
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Your district email address:
*
Confirm email address:
*
Your position
Which of the following best describes the reason for your anticipated leave:
*
My own medical condition
Medical condition of a family member
Maternity/paternity leave
Other
Please indicate your relationship to the family member:
*
Because you selected "other," please describe the reason below:
*
Anticipated due date:
Anticipated due date:
*
/
MM
/
DD
YYYY
Approximate start date of anticipated leave:
Approximate start date of anticipated leave:
*
/
MM
/
DD
YYYY
Approximate end date of anticipated leave:
Approximate end date of anticipated leave:
*
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MM
/
DD
YYYY
Which of the following best describes your anticipated leave:
*
I will be out every day during the time period above
I will be out intermittently during the time period above
Other
Because you selected "other," please describe below:
*
Please sign below and submit to complete your leave of absence inquiry:
*
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or
Type
I understand this field is a legal representation of my signature.
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Full Name
I understand this field is a legal representation of my signature.