Email Address:
Report Date:
Date(s) of Absence:
Reason for absence (Check one):
Personal Leave
Bereavement
Illness
Medical Leave
Professional Leave
Vacation
Without Pay
Other
Other Explanation (to be filled out only if other box is checked):
Reason for Absence:
I hereby apply for leave of absence I have been absent on the following dates:
Beginning (first day of absence) Ending (last day of
absence) Total work days:
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For administration use only:
Approved Disapproved
Food Service Manager: Dana Fisher
Date:
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For Secretary use only:
Substitute's Name: