Leave of Absence Request - Laurel Springs School Family Center
Leave of Absence Request Laurel Springs School Student name: __________________________________________________________________ 302 W. El Paseo Rd. Ojai, CA 93023 Date: ____________ 1615 W. Chester Pike West Chester, PA 19382 Name of person reporting: ________________________________________________________ 855.658.8682 805.646.0186 fax Relation to student: ______________________________________________________________ www.LaurelSprings.com 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. www.LaurelSprings.com 855.658.8682
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