Name __________________________________________ Date _________________

Date of Requested Absence(s) _________________________________

Signature ______________________________________________________________

Board policy for personal leave includes, but is not limited to, the following conditions:

ARTICLE V - LEAVES

D-3 Not more than five teachers may be absent at one time on personal days.

D-4 Personal days may not be used during the first or last week of the school term.

D-5 Personal leave may not be used contiguously with Thanksgiving, Christmas, or Easter

vacations unless prior administrative approval is given.

D-6 In emergencies, the administration may waive the conditions of the above.

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( ) Approved

( ) Approved (Applied to Sick Leave)

( ) Not Approved (Exceeds allowable number)

( ) Not Approved (Entitlement used up)

( ) Not Approved ( Not permissible date)

_______________________________ Signature _____________ Date