Time Off Request Form

This form is used when time away from work is requested.

A minimum of a two-week notice is needed.

Four week notice is needed for holidays.

Name:_________________________________________________________

List the shifts for each date being requested off.

If there is more than one shift per client, list separately.

Client’s Name

Date

Time of Shift

Coverage

(example 10am – 3pm)

(Office Use Only)

Do you wish to use vacation time: Yes / No How many hours? __________

Caregiver Signature:______________________________________________

Date:___________________________________________________________

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Parent category: Business