Leave Request Form

Leave Request Form

Fill out this form to request a leave. The submission will route to Human Resources for review. For questions, please contact Toni Bahl at tbahl@orionassoc.net or 763-450-5003 or Andrea Hagen at ahagen@orionassoc.net or 763-450-5008.
Company*
Select your relationship to the employee*

SupervisorSelf (I am the Employee)Other
Employee Legal Name

Legal First NameLegal Last Name
Employee Email
example@example.com
Employee Phone Number*
Please enter a valid phone number.
Location*
Program or Department*
Position
Supervisor Legal Name*

Legal First NameLegal Last Name
Supervisor Email *
example@example.com
Type of Leave
Select the type of leave requested*

Employee's own serious medical condition (including pregnancy)Bonding leaveAdoption leaveFamily member's serious medical conditionCare of service member with serious injury or illnessMilitary caregiver leave for qualifying contingencyEducational/school leavePersonal leaveUnknownOther
Describe the family member or service member's relationship to the employee*
Mother, father, sister, etc.
Do you know the estimated start and end date of the leave?*

YesNo
Start Date of Leave*

MonthDayYear
Date
End Date of Leave*

MonthDayYear
Date
Comments
Supporting documentation (if applicable)

Cancelof
Would you like to continue receiving emails regarding company events or promotional opportunities while on leave?

YesNo
Signatures

I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
Name of person filling out the form*

Legal First NameLegal Last Name
Email of person filling out the form*
example@example.com
Signature*

Clear
Date of Signature*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Leave Request Form

Type of Leave

Signatures