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Request for Family or Medical Leave must be made, if practical, at least 30 days prior to the date the requested leave is to
begin. This form must be completed and submitted within 24 hours of the Director being notified.

To be completed by the employee:
If the employee is not available, the Director must complete this form:

Employee Name:_________________________________________________                   EE#:___ ___ ___ ___ ___ ___ ___ ___
                                                                                       Last 4 of Social Security Birth Month Birth Day
CNI School #:______________________________________________ Hire Date:___________________________

I request family or medical leave for one or more of the following reasons:

________          Because of the birth of my child and in order to care for him or her
                  Expected date of birth _____/_____/_____ Actual date of birth _____/_____/_____

________          Because of the placement of a child with me for adoption or foster care placement

________          In order to care for my spouse, child, or parent who has a serious health condition

________          For a serious health condition that makes me unable to perform my job

I expect to begin this leave on _____/_____/_____            My expected return date is _____/_____/_____
Have you taken a family or medical leave in the past 12 months? ______Yes ______No
                   If Yes, when? _________________________

I understand and agree to the following provisions:
     I have worked for Childcare Network at least one year and at least 1,250 hours in the previous 12 months.
     The time taken on this FMLA will be counted against the 12 weeks allowed under FMLA guidelines. Childcare
        Network uses “a rolling 12-month period looking backward” to measure FMLA leave. This means that you will not
        be eligible for more than 12 workweeks of FMLA in any 12-month period.
     I understand that I will be required to furnish an original medical certification of a serious health condition. This
        documentation must be given to my Director within 15 working days. Failure to provide this documentation may
        result in disqualification of FMLA and related benefits.
     While I am on leave, I will be required to furnish periodic recertification (original documents). Also, one week prior
        to the approximate release date given from my doctor at the time my leave began, or one week prior to the actual
        release date, (whichever is earlier), I will furnish recertification from the doctor regarding continuation of leave or
        release to return to work.
     While on leave, I will be responsible for any insurance benefit premiums by submitting payment, either bi-weekly
        (due every payday) or a lump-sum payment in advance, to the corporate office.
     If I do not return to work on the ‘expected return date’ or fail to make specific arrangements with my Director
        regarding an extension of time, it will be considered that I voluntarily left my employment with Childcare Network.

Employee’s Signature__________________________________________                    Date_________________________________


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