Parental Leave Application Form
Use this form to apply for unpaid Parental Leave. Before completing the form, please refer to the Leave
Entitlements Policy to understand your entitlement and to ensure that you qualify for Parental Leave.
Give a copy of the completed from to your manager to sign and keep a copy for your records.
Your details (Please complete all fields)
Name: Job title:
Entitlement to Parental Leave (Please complete all fields)
Start date (of continuous employment):
I will have 52 continuous weeks service at the date my Parental Leave commences.
I will not have 52 continuous weeks service at the date my Parental Leave commences.
Date of birth/adoption:
Is your child disabled (i.e. getting disability living allowance)? Yes: No:
I declare that… (Complete as appropriate)
I am a parent named on the child’s birth certificate, or
I am named on the child’s adoption certificate, or
I have legal parental responsibility for a child under five (18 if disabled)
Request (Please complete all fields)
I wish to start my Parental Leave on:
I will return to work on:
Comments (Add any comments as appropriate, and sign and date the form)
Please accept this notification as an application for Parental Leave.
I have completed this form to the best of my knowledge and fully understand the terms and conditions. I understand that I must take my Parental Leave in
multiples of one week. No more than four weeks leave may be taken in a year and no more than 13 weeks for each child up to their fifth birthday.
Approved: Yes: No: Comments:
signature: nature: Name: Date:
Send the form to the HR representative.