Leave of Absence Request

(All Fields Required)

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).