Area 705 Roller Derby
Leave of Absence Request Form
Name:
Derby Name:
Derby Number:
CRDI Number:
Committee Position Held:
Telephone:
Type of Leave (check below):
Leave Start Date: __________________________________
Anticipated Return: ________________________________
[ ] Injury Leave
[ ] Personal Leave
[ ] Vacation Request
Details of Injury
Please describe your injury here. A Physician’s Letter may be required by the Executive
Committee for approval of absence or to return to skating.
Request for an Extended Leave of Absence
Are you requesting an extension? [ ] Yes [ ] No
If “yes”, indicate the dates of the original leave
From ________________________________ to _______________________________
Signature
I have read and understand the Area 705 Roller Derby policy titled “Leave of Absence” and
certify that the information provided is true and complete.
Signed: __________________________________ Dated:_____________________________
[ ] I have attached a written letter requesting approval for absence from league events.