Leave of Absence Request - Laurel Springs School Family Center

Leave of Absence
Laurel Springs
Student name: __________________________________________________________________
302 W. El Paseo Rd.
Ojai, CA 93023
Date: ____________
1615 W. Chester Pike
West Chester, PA 19382
Name of person reporting: ________________________________________________________
805.646.0186 fax
Relation to student: ______________________________________________________________
School Code: 052256
Enrollment start date: _______________________ End date: _________________________
(This is found on your welcome email)
Dates student could not work: ______/______/______—______/______/______
(Maximum time for Leave of Absence is 3 months)
If student is still unable to work, what is the anticipated return date?___________________
Reason for Leave of Absence (LOA) ____Medical ____Family Crisis ____Other
(Please mark all that apply)
Please explain:
Please attach doctor’s note or any pertinent supporting documents.
Read the statement below, sign, and return via fax, mail, or email to [email protected]
I attest that this information is true and correct. Please process my request for the Leave of Absence for my child. I understand that the
maximum length of time that can be approved is 3 months.
Parent Signature: __________________________________________________________ Date: ____________________
Email address: ____________________________________________________________
Within 14 days of receipt of this form to Student Services, a decision will be emailed to the address listed above.