Address: 800 Tydings Lane, Havre de Grace, Maryland, 21078, US
Telephone: 800-799-4673

Leave of Absence’s are reserved for legal, medical and other outside appointments as well as post family session trips and typically only last a few hours.
Please allow for 48 hour notice for Leave of Absence approval so that pick up and return time may be coordinated with staff.
Leave of Absence passes must be approved by assigned Counselor, Director of Emerging Adult Services or Extended Care Operations Manager.

Name*
First Last
Date*
MM slash DD slash YYYY
Requested Date of LOA*
MM slash DD slash YYYY
Estimated Time of Departure*

: Hours

Minutes

AM/PM
Date of Return*
MM slash DD slash YYYY
Estimated Time of Return*

: Hours

Minutes

AM/PM
Individual who will be picking up for LOA:*
Please describe nature of the LOA, places you will visit, people you will see, and tasks you hope to accomplish:*
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Leave of Absence Request

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