Time Off Request (Employees)

First Name

Last Name

Phone Number

Are you requesting full days off or a modified day (i.e. for doctor's appointments, events for kids, etc.)? Choose one or both:

Full days off

Modified days

Date(s) and time(s) requested

Have you checked the calendar to coordinate with other staff requests or important events?

Yes

No

Salaried employees: When do you plan on making up these flex hours? Please list the dates and times.

Signature

Type Name Here (Secondary Signature)

Today's Date