Time Off Request Form

Time Off Request

I would like the following dates off.

Date(Required)

Email(Required)

Name(Required)

First Last

Reason for time off?(Required)

How much time off are you requesting?(Required)

Day Needed Off

Additional Day

For additional vacations, please submit an additional form.

First Day of Vacation

Last Day of Vacation

Return to Work Date

Who will be covering your shift(s)? If not yet confirmed, please list who you have contacted.

Please list the staff member(s) who have confirmed they will cover your shift(s):

Additional Comments?

Name of coordinator/manger who approved this request:(Required)