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Date:	______________________________
TO:	Mr. Miguel Torres, Principal Educational Alternative Outreach Program
FROM:	______________________________
SUBJECT:	MEDICAL/DENTAL EXAMINATION LEAVE

I am requesting permission to be released from my duties due to the following scheduled medical/dental appointment:

Date of appointment:	______________________________
Release time:	______________________________
Authorization by assigned assistant principal:	______________________________

NOTE:         This request must be reviewed and recommended by the employee's assigned assistant principal, before it is sent for approval by the principal.  The assistant principal will indicate recommendation by signing above.

Principal releases unit employees for up to two (2) hours without sick leave being charged against the employee for the purpose of medical and/or dental examination and if deemed necessary, with verification upon return.  (Article XIV, Section 7, UTD/M-DCPS contract)

Approved:	______________________________
	Miguel Torres, Principal
Date:	______________________________

 xc: Payroll Clerk