Leave of Absence Request Form

Request for leave of absence including leave under the Family and Medical Leave Act (FMLA)

Employee Number (EID)*

Name*

Park*

Select

Absence Reason*

I request a family or medical leave of absence for the following reason:

Select

Health Condition

Select or enter value

Aware of Leave*

I first became aware of the need for me to take leave on:

Date of Leave*

I am requesting leave beginning on:

Return to Work

I anticipate that my leave will conclude and I will return to work on:

Email Address*

Preferred Method of Communication

Select

Phone Number

Acknowledgement

I understand that I will be required to substitute paid leave that i have accrued, such as vacation, sick and personal days, for unpaid FMLA leave. After my accrued paid leave is exhausted, my leave will be unpaid.

I understand*

Acknowledgement

I understand that, if my request for leave is based on my serious health condition or that of an immediate family member, I will be required to obtain and furnish a certification from a health care provider within 15 days of this request. I understand that Six Flags Inc. may under certain circumstances then require me or my family member to be examined by a doctor of Six Flags Inc. choice. If there is a difference of medical opinion, I understand that my family member or I may be required to be seen by a third, jointly designated doctor. This third opinion will be final and binding. The cost of any second or third opinion will be borne by Six Flags Inc.

I understand*

Acknowledgement

I understand that any false statement on this document or about the circumstances of or reasons for my request for family or medical leave will be grounds for discipline and/or termination of my employment with Six Flags Inc.

I understand*

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You can upload any documents regarding your leave of absence to provide to Human Resources.

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