Staff Leave Application Survey

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1.	Teacher's Name*

2.	Type of Leave*

3.	If you selected convention, workshop or other please provide the name of the event or other description.

4.	1st Day of Leave*
	mm/dd/yyyy

5.	2nd Day of Leave
	mm/dd/yyyy

6.	3rd Day of Leave
	mm/dd/yyyy

7.	4th Day of Leave
	mm/dd/yyyy

8.	5th Day of Leave
	mm/dd/yyyy

9.	Total number of work days you will be gone.* Please don't count weekend days.

10.	Name of Substitute(s):* Please enter all of the subs (and their specific dates) if you are using more than one. Please enter n/a if no sub is needed.