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.

All Leave of Absence requests for medication require 72-hour notice, not including weekends or holidays.

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

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

If you have any questions, please contact:
- Jody Young, Director of Resident Services x2011
- Jessi Young, Director of Social Work and Admissions x2064
- Chris Shepperd, Social Worker x2047
- Mikayla Perkins, Social Worker x2058
Should be Empty: