Reason for Requested Leave
a. The Birth of a child, or placement of a child with you for adoption or foster care
b. Your own serious health condition
c. Because you are needed to care for your spouse, child or parent due to his/her serious health condition*
d. Because of a qualifying exigency arising out of the fact that your spouse; parent; son or daughter is on
active duty or call to active duty status with the Armed Forces.*
e. Because you are the spouse, son or daughter, parent, next of kin of a covered service member with a
serious injury or illness.*
If "c" "d" "e" please check one and fill out the information below:
Child Parent
*Name
*Address
*City, State, Zip
* Date of Birth
Note: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting
or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law,
we are asking that you not provide any genetic information when responding to this request for medical information. "Genetic information" as defined
by GINA, includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an
individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family
member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.
Spouse
FMLA Start Date FMLA End Date
Signature Date
La Joya Independent School District
Application for Family and Medical Leave
Employee Name Employee ID #
Phone #Employee Address City, State, Zip Code
Employee Position Campus/Department
