Cobb County School District
Form GARH-10
A community with a passion for learning!
Human Resources/Benefits Office
REQUEST FOR MATERNITY/ADOPTION LEAVE
Employee's Name:
________________________________________________________________
Last
First
Middle
Home Address : ________________________________________________________________
Street
________________________________________________________________
City
State
Zip
Social Security Number: XXX-XX_______________
Work Telephone # ____________________
Home Telephone # _________________
Work Site:________________________________
Position: _______________________________________________________________________
Date Requested to Begin Leave:______________ Date Requested to End Leave:_____________
______________________________________________________________________________
Employee’s Signature
Date
______________________________________________________________________________
Principal’s Signature
Date
Check type of Maternity Leave
Adoption of a child.
Certificate statement required that an adoption has occurred or is imminent.
(Required certificate must be provided or commencement of leave may be delayed)
Childbirth.
Form GARH-2 (Physician's Statement of Disability) is required to certify disability dates.
(Required certificate must be provided or commencement of leave may be delayed)
Forward to the Human Resources Benefits Office
P.O. Box 1088
Marietta, Ga. 30061
(770)426-3537 (770)514-3871 (fax)
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Human Resources/Benefits Office Use Only
APPROVED BY: _______________________________________________________________________________
Benefits Office
Date
7/19/12