Caregiver Time Off Request Form

Caregiver Time Off Request Form

Please Note: Vacation requests should be made at least 2 weeks in advance whenever possible. If you need to call off a shift that is within the next 2 weeks, please call the local office and Press option 3 then option 2.
Location*
Today's Date*

MonthDayYear
Date
Caregiver Name*

First NameLast Name
Caregiver Email Address*
example@example.com
Shift(s)*
Unpaid VacationPaid Sick Leave
Please Note:

Paid Sick Leave can be requested when a caregiver needs time off of work due to an existing health condition or due to preventative care for self or a “family member,” including a child, parent, spouse, registered domestic partner, grandparent, grandchild, or sibling.

Unpaid Vacation needs to be requested atleast 2 weeks in advance whenever possible.

*Submission of this form is not automatic approval of Paid Sick Leave or Unpaid Vacation time. Please confirm with the office your request was received once submitted. You are also given the option after submitting the form to perform edits in the instance you made an error on your original request.*
Notes*
Should be Empty: