TODAY'S DATE:_______________________

KIDS AND COMPANY

TIME OFF REQUEST

I, __________________________________________________________ , request to be off work on

Date: ____________________________________ Time: _______________________.  I will return

Date: ____________________________________ Time: ________________________________ .

Reason: _________________________________________________________________________

I would like to use: ______ Sick leave, _______ Vacation time, _______ Personal time (without pay)

Sub Name: ____________________________________________ Phone #: ___________________

(You are required to line up a sub or have the Lead Teacher/Site Director initial one is not needed.)

Sub approval: _______________________________________________________________________

Lead Teacher/Site Director initials required for:  _________ Sub not needed    ____________ Approval

________________________________________________________________________________

For Office Use:  Time earned to date: _____________ Vacation  ______________ Sick Time

Comments: ____________________________________________________________________

Received Date: ________________________________ Approved for:    Pay         No Pay

Denied (Reason): _________________________________________________________________

________________________________________        _____________________________________

Executive Director                                                                    Date

• Copy to Sub (if applicable)                                              *  Marked on calendar

• Copy to Employee                                                            *  Marked on time sheet

• Copy to Personnel File

Form revised on web site: 11/26/2003