Leave of Absence Request Form
Use this form to request a leave of absence from Park City Rotary. A leave of absence is granted for up to six months per request. During this time a Rotarian must maintain Rotary Club dues but will be excused from paying for lunches and meeting attendance requirements.
Member Name
First Name
Last Name
E-mail
Contact Number
-
Area Code
Phone Number
Leave Start Date
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2020
2019
2018
2017
2016
Year
Leave End Date (Please estimate. Maximum 6 months from Start Date.)
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2020
2019
2018
2017
2016
Year
Reason
Work/Business Demands
Personal/Family Illness
Dissatisfaction with Rotary
Other
Additional Comments
Submit
Should be Empty: