The Virginia Home - Leave of Absence Form

Leave of Absence Form
Resident Name

First NameLast Name
Today's Date

MonthDayYear
Holiday/Occasion
Pick-Up Date

MonthDayYear
Pick-Up Time

Hour Minutes

AM/PM Option
Return Date

MonthDayYear
Return Time

Hour Minutes

AM/PM Option
Contact Information of person picking up and returning resident
Supplies Needed
Dietary Request (early tray or hold tray, etc)
Additional Notes:
Your cooperation on the following timelines for submission would be greatly appreciated.

10 days prior to Thanksgiving, Christmas or New Year's holidays

10 days prior to extended Leave of Absence such as family vacation (more than 2 overnights)

3 business days for shorter Leave of Absence (1-2 overnights)

3 business days for extended day (no overnight) Leave of Absence that requires medication

If you have any questions, please contact:
- Jody Young, Director of Resident Services x211
- Jessi Young, Director of Social Work and Admissions x264
- Susan Eads, Social Worker x247
Should be Empty: