Fillable Printable Child Care Leave Form - Spackenkill Union Free School District
Fillable Printable Child Care Leave Form - Spackenkill Union Free School District
Child Care Leave Form - Spackenkill Union Free School District
Spackenkill Union Free School District
CHILD CARE LEAVE FORM
I plan to use ______ days (up to 40) of my accumulated
sick leave for pregnancy related disability (letter of request
to the Superintendent and a doctor’s note is necessary)
from _____________ to _____________.
(Date) (Date)
I plan to use Family Medical Leave to continue my
health insurance coverage for twelve weeks
from _____________ to _____________.
(Date) (Date)
(FMLA and pregnancy related disability run concurrently.
Form is available in Personnel Manual and submitted
to the Superintendent.)
I plan to use unpaid child care leave
from _____________ to _____________.
(Date) (Date)
_________________________ ____________
Signature Date
