Instructions to Employee: Please complete all applicable fields. If during the duration of this benefit you anticipate taking time off (PTO or leaves of absence) greater than one week please fill out section 1A. This form should be submitted to your Administrative Director as early as possible but generally at least 2 months in advance of anticipated time of use. Once you have completed this form, your Administrative Director will get a notification to review and follow up with you.

Click here to view the Lactation Support guidelines or the FAQ.