Leave Of Absence Form - Wellesley Public Schools printable pdf download

Leave Of Absence Form - Wellesley Public Schools

Wellesley Public Schools

Wellesley, MA

Leave Request Form

EMPLOYEE REQUEST

Employee Name:

Job Title:

Building/Location:

Supervisor:

Full Time:

Part Time:

If Part Time, please list FTE:

I am notifying you of my request to take a leave of absence due to:

The birth of my child, placement of child in my home for adoption or foster care

(projected date of birth/adoption)

A serious health condition for which I need care (requires physician certification form)

A serious health condition affecting my ( ) spouse, ( ) child, ( ) parent, for which I am needed to

provide care. (requires physician certification form)

Discretionary Leave after a maternity leave (WTA Unit A & B members only – Article 10)*

Alternative Employment Leave(WTA Unit A & B members only–Article 10–Deadline March 1st)*

Discretionary Leave (WTA Unit A & B members only – Article 10-Deadline March 1st)*

Educational Leave (WTA Unit A & B members – Article 11-Deadline October 31

)

Military Expansion Leave

Other (describe below)

*Applications for leave are for one year. Applications to request a second year leave of absence must be

received by January 15

Reason for leave:

Year Leave Request

My requested leave is expected to be on a

continuous

intermittent

reduced schedule basis

(describe)

If requesting a reduced FTE schedule, please list the FTE amount of leave requested:

My requested leave is to begin on:

and continue through:

(date)

Intended Return date:

(date)

Leave Of Absence Form - Wellesley Public Schools