Women’s Extended Care Program

Leave of Absence Request

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.

WEC Leave of Absence Request Form

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

: HH

MM
Date of Return*
Date Format: MM slash DD slash YYYY
Estimated Time of Return*

: HH

MM
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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