Benefits Office
APPLICATION FOR FAMILY MEDICAL LEAVE ACT/
CALIFORNIA FAMILY RIGHTS ACT LEAVE
NAME : _________________________________ DIVISION:___________________________________
SOC. SEC #: ______________________________CAMPUS:___________________________________
Beginning Date of Leave: ____________________ Ending Date of Leave:________________________
Reason for Leave (check one):
________(a) birth or adoption of a child, or the receipt of a child into foster care, within one year of such birth or
placement, or
________(b) the employee’s own serious health condition, or
________(c) a serious health condition of an employee’s eligible child, spouse/domestic partner, parent
or member of the immediate household, which requires the employee to care for the family member or
during which the employee’s presence would be beneficial.
A serious health condition means an illness, injury, impairment or physical or mental condition which
involves either inpatient care of continuing treatment or supervision by a health care provider and does
not include a cold or flu, as more fully described in the attached separate statement.
Explanation (if necessary): _______________________________________
A leave request based on an employee’s serious health condition or the serious health condition of an
employee’s spouse/domestic partner, child, parent or member of the immediate household must be
accompanied by a verifying medical certification from a physician.
I hereby authorize the Yosemite Community College District Office of Human resources to contact my
physician to verify that the reason for my requested leave is my own serious health condition, or that of
my qualifying person. I understand the diagnosis will not be discussed.
I concur with the terms and conditions of the leave and understand that it will be my obligation to
return to District employment on the working day following the ending date of the leave. I am aware
that failure to return from leave may be construed as abandonment of my position.
____________________________________________________________ ______________________
Signature of Employee Date
REVIEWED BY:
____________________________________________________________ ______________________
Immediate Supervisor Date
___________________________________________________________ _________________________
Vice Chancellor of Human Resources Date
