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
Leave End Date
Leave Start Date
Please select a month
January
February
March
April
May
June
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August
September
October
November
December
Month
Please select a day
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Day
Please select a year
2030
2029
2028
2027
2026
2025
2024
Year
Leave End Date (Please estimate. Maximum 6 months from Start Date.)
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
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5
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Day
Please select a year
2030
2029
2028
2027
2026
2025
2024
Year
Reason
Please Select
Work/Business Demands
Personal/Family Illness
Travel/Vacation
Dissatisfaction with Rotary
Other
Additional Comments
Submit
Should be Empty: