Leave of Absence request

    First Name

    Last Name



    Proposed Start Date

    Proposed Return Date

    Reason for Leave of Absence

    Yes, I understand that these are reviewed on a weekly basis and that I am also responsible for completing the E- Form that will be sent to me once approved for this Leave of Absence to be valid.

    I understand that I can take up to two LOA’s per enrollment and it must be a minimum of two weeks. The maximum time you can take is 60 days (2 months).