School District Of New London Application For Family And Medical Leave Form
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1SCHOOL DISTRICT OF NEW LONDON
APPLICATION FOR FAMILY AND MEDICAL LEAVE
(return this Application to the District Office)
Name:
Position:
When did you initially contact the District regarding your request for leave of absence?
1.
Whom did you contact?
2.
How was the person contacted?
Phone
E-mail
Other:
4.
I hereby request a leave of absence under the Federal and Wisconsin Family and Medical Leave Act laws.
The leave of absence is requested for the following reason (please check the appropriate box):
a.
The birth of my son or daughter and to care for such child.
b.
The placement of a son or daughter with me for adoption.
c.
The placement of a son or daughter with me for foster care (FMLA only).
d.
To care for my
spouse,
child (age:
), or
parent who has a serious health
condition.
e.
My serious health condition that makes me unable to perform the essential functions of my
job.
5.
Start Date of Anticipated Leave:
6.
Expected Date of Return to Work:
Note:
Reasonable notice is expected when requesting time off. An employee must schedule leave for planned medical
treatment in a manner that does not unduly disrupt the operation of the School District of New London.
An employee requesting leave for the employee’s serious health condition or the serious health condition of the
employee’s family member must submit a verifying medical certification from a physician with fifteen (15) calendar
days of application for leave or within fifteen (15) calendar days of other requests by the School District of New
London.
By execution of this request form, I hereby authorize the Health Care Provider, as my duly authorized
spokesperson, to provide such medical information as requested on the attached Certification of Health Care
Provider by the School District of New London, without liability for such release of information.
I understand that this application is valid for the above reason and time period only, and a failure to return to
work at the end of my leave period my be treated as a resignation unless an extension has been agreed upon and
approved in writing by the School District of New London.
Date: _____________________
______________________________________________
Employee Signature
RECEIVED BY DISTRICT ADMINISTRATOR:
Date: __________________________
______________________________________
District Administrator Signature
Revised: February 2014
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