PCA PTO Request

PCA PTO Request
If you are using your PTO in place of a shift, you must inform your client/responsible party of your anticipated absence and gain their approval before submitting this form. If you are using your PTO during a time in which your client is in a hospital or other care facility, you may use your PTO without notifying your client/responsible party.

Your PTO balance can be found by logging into your ADP account. If you do not know your login information, please try to use the "Forgot your User ID?" link on the ADP Login Page before contacting an administrator.

Agency Name: A Chance To Grow, Inc.
Agency Phone Number: (612) 789-1236
Name:

First NameLast Name
List the dates you would like to use PTO:
How many hours of PTO would you like to use each day?
Total amount of PTO hours you would like to use?
I verify that if I am using my PTO in place of a shift, I have informed my client of the absence I will be taking. I authorize A Chance To Grow to apply this PTO to my timecard for the dates specified in this form. (signature below)
Signature:*

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Date:*

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