Educational and Professional Leave Form

Education and Professional Development Leave Application Form 9/9/19, 7'28 AM
Education and Professional Development Leave

Application Form
The purpose of Education and Professional Development Leave is to provide an educational and
professional opportunity for staff to enhance their individual and professional effectiveness. The
types of activities that may warrant this leave include experiences such as job shadowing in an
applicant’s respective industry or gaining clinical experience for a graduate program.
Prior to submitting your application, please have a conversation with your supervisor to obtain their
verbal approval and to determine the department plans for replacing your work responsibilities.
Once the application is submitted, your supervisor will receive an electronic copy as a confirmation
of your submission.
ACKNOWLEDGEMENTS
By providing my electronic signature to this application I acknowledge that my proposal has been
discussed and approved by my supervisor. I understand that my Campus President/Vice President
will have final approval before my application is reviewed by the committee.
If granted Education and Professional Development Leave:
I agree to abide by the terms of Valencia’s Education and Professional Development Leave
Policy .
I understand that within four months following the completion of my leave, I am responsible
for submitting an Education and Professional Development Leave Report summarizing the
benefits and/or achievements resulting from the Education and Professional Development
Leave.
I understand that employee health insurance benefits may continue while on Education and
Professional Development Leave.
I understand that any travel conducted while on Education and Professional Development
Leave is at my own risk. It is recommended that additional medical/trip insurance is
purchased at my own expense to cover unanticipated travel issues.
Valencia College shall not be responsible for the payment of emergency expenses incurred
should I experience illness, accident, or injury during the period of Education and
Professional Development Leave.
APPLICANT INFORMATION
First Name *
Last Name *
VID Number *
https://form.jotform.com/82194645278972 Page 1 of 3
Job Title *
Department *
Campus *
Mail Code *
Email *
Office Phone *
Only numbers, no dashes please
IMMEDIATE SUPERVISOR INFORMATION
First Name *
Last Name *
Email *
CAMPUS PRESIDENT/VICE PRESIDENT INFORMATION
Campus President/VP
First Name *
Campus President/VP
Last Name *
DATES OF ANTICIPATED LEAVE:

Leave must begin between May 1, 2020 and April 30, 2021.
Anticipated Start Date mm-dd-yyyy

Date
Anticipated End Date mm-dd-yyyy

Date
AWARD CRITERIA
The leave is granted to acquire additional knowledge and competency in an employee's respective
field to support the mission of the College.
Applications meeting the Education and Professional Development Leave Policy’s criteria as listed
in Policy: 6Hx28:3D-11 will be ranked using the following criteria (in order of relative importance):
a. Evaluation of application information with respect to the principles and criteria stated in this
policy and implementing procedures.
b. Exceptional service to the college or community.
c. The number of prior Education and Professional Development Leaves
d. Number of years of applicable Valencia service to the applicant.
Provide a 2-3 sentence

description of your
leave proposal: *
REQUIRED ATTACHMENTS
1. A typed, detailed Education and Professional Development Leave Proposal. Within the context
of the proposal, be sure to include the following:
Description of how you will utilize leave for educational and professional enrichment
Summary and purpose of activities spent during the leave; and how these activities will
enhance your ability to contribute to the mission of the college
Specific intended outcomes of the leave
* Choose File no file selected
2. A resume demonstrating exceptional service to the college.
* Choose File no file selected
Electronic signature
(Your Name) *
Submit

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Education and Professional Development Leave Application Form 9/9/19, 7'28 AM

Education and Professional Development Leave

If granted Education and Professional Development Leave:

IMMEDIATE SUPERVISOR INFORMATION

CAMPUS PRESIDENT/VICE PRESIDENT INFORMATION

DATES OF ANTICIPATED LEAVE:

Anticipated Start Date mm-dd-yyyy

Anticipated End Date mm-dd-yyyy

Provide a 2-3 sentence

* Choose File no file selected

2. A resume demonstrating exceptional service to the college.

* Choose File no file selected

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