Furlough Referral Form

Yoakum ISD G/T Furlough Referral Form

Date: ___________________________

Requested by: _____________________________________________

☐ Check here if you have read and understand the Yoakum ISD Furlough Policy.

Requested for (student's name): _______________________________

Date: ____________________ Length of time requested: ___________

Reason(s) for request: _______________________________________

__________________________________________________________

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Committee Decision

______ Furlough granted     ______ Furlough denied

Date: ____________________ Length of time granted: _____________

Comments: ________________________________________________

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Committee Members

________________________________
G/T Coordinator/Teacher

________________________________
Principal/Counselor

________________________________
Teacher

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Other (Specify)