Leave of Absence Request Form

This form is a Leave of Absence request form.
Filling this form out and sending it, does not guarantee that your leave was approved.
This form can only be used for a Leave of Absence Request.

Please make sure you read ARTICLE XX - LEAVE OF ABSENCE of the Bay Shore Brightwaters Rescue Ambulance INC. By-Laws to determine if you are eligible to request a leave of absence.

Leave of Absence Request

* Indicates required field

Name *

First

Last

Email *

Phone Number *

I am requesting a Leave of Absence for *

General Leave of Absence Article XX Section 1 Military Leave Article XX Section II Medical Leave Article XX Section III Maternity/Paternity Leave XX Section IV Emergency Leave XX Section V

Date you are requesting to start the leave.

Month *

Day *

Year *

Return Date *

I have a return date My return date is unknown at this time

Date you are expected to return. If you do not know the date of your return, click the unknown at this time box above.

Month *

Day *

Year *

List the valid reason for your leave request. Example military orders, birth of baby, surgery, death in family *

Upload Required Documentation, ex. Doctor's note *

Max file size: 20MB

Submit

Members

Home

Committees

3-24-1
ALS
BLS Restock
Bike Team
By-Law
CPR
Dinner Dance

Driver Training
Ducks
Field Training
Fundraising
Good and Welfare
House
Kitchen Restock
Membership/Recruitment

OSHA/Infection Control
Probationary Training
QA/QI
Recreation/Game Room
Special Awards
Uniform
Website/Public Relations