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Yadkin County Schools
Where you can Succeed
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Employee to complete:
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Name
Social Security Number
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School / SiteCurrent Position
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Type of Leave Requesting - check oneForms highlighted must be attached
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MaternityForm WH-380 E (For the use of Employee FMLA)
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Medical Form WH-380 F (For the use of Family FMLA)
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FamilyApplication/Donation for Voluntary Shared Leave
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Educational Must have proof of 12 semester hours per year
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Leave of Absence without payWritten Request
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Military Certification from Branch of Service
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Worker's CompForm 19
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Anticipated/Actual Leave DatesLeave Schedule - check one
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Beginning Date
(First day out)		Continuous
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End Leave Date
(Return to work)		Reduced Schedule
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Intermittent
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Employee Signature DatePrincipal Signature Date
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For OFFICE use only:
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For Maternity Leave ONLY-choose the order to use available leave - i.e., 1, 2, 3, 4, 5
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Sick LeaveExt. SL (if applicable)Annual Leave
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PL (if applicable)No Pay
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FMLA BeginsFMLA Ends
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Submitted byDate
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Form revised - 5/11/2022
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