Request Time Off • Caregiver

REQUEST TIME OFF FORM • CAREGIVER

Kindly accomplish this form for TIME OFF / LEAVE requests
Caregiver Full Name*
First Name & Last Name
Are you taking off a portion of the day or a whole day(s)?*

All DayPartial Day
Leave Start Date*
Leave End Date *
Leave Start Date*
Leave End Date*
When will you be able to resume work?*
Reason for Request Time Off*

Vacation - Out of CountryVacation - Out of TownPersonal LeaveFuneral or BereavementJury DutyFamily ReasonsMedical LeaveTo VoteOther
Time Off Remarks*
Kindly let us know why you're requesting for leave, and indicate the exact time for partial day leave.
TERMS & CONDITIONS

As per Nest & Care's policy:

📌 I understand that this request is subject to approval by my employer.

📌 I understand that the office staff will contact me to verify the information submitted and inform me if my request for time off has been approved or denied.

📌 I understand that by signing and submitting this form, I agree with the company's terms and conditions above.
Signature*
Business Address: 1751 Elton Rd, Ste 210 Silver Spring, MD 20903

Phone: (240) 690-9900 • Fax: (240) 645-4056

Website: nestandcare.com • Email: care@nestandcare.com
Should be Empty:

REQUEST TIME OFF FORM • CAREGIVER