Unpaid Parental Leave

Application Form

Before completing this form, please read the Unpaid Parental Leave section in the UECS Family Leave Policies document.

You should download this form and save it on your computer before completing it.

Employee Details

Surname:	Click to enter text	Forename/s:	Click to enter text
Department:	Click to Select	Name of Manager:	Click to enter text

Details of Parental Leave

You can take a maximum of 4 weeks parental leave in any 12 month rolling period after one year’s qualifying service. This must be taken in blocks or multiples of one week. A maximum of 18 weeks can be taken before a child’s 18th birthday.
Child’s date of birth:	Click to enter date of birth
Number of weeks you wish to book:	Click to Select
Week 1 date commencing:	Select start date
Week 2 date commencing:	Select start date
Week 3 date commencing:	Select start date
Week 4 date commencing:	Select start date
Parents of children who are in receipt of either Disability Living Allowance or Personal Independence Payment can take parental leave in periods of less than one week.
I confirm that I am in receipt of DLA for my child:	☐
I confirm that my child receives PIP:	☐
And I wish to book the following dates:
Date from:	Select start date	Date to:	Select end date
Date from:	Select start date	Date to:	Select end date
Date from:	Select start date	Date to:	Select end date
Date from:	Select start date	Date to:	Select end date
Date from:	Select start date	Date to:	Select end date
Date from:	Select start date	Date to:	Select end date

Employee Declaration

I confirm that I am named on the child’s birth / adoption certificate, or I have parental responsibility for the child (or will have by the date the unpaid parental leave commences):	☐
I confirm that the child is below the age of 18:	☐
I confirm during the period of unpaid parental leave I will care for the child or make arrangements for their welfare:	☐
Print Name:	Click to enter text	Date Signed:	Select Date …
Signed:
Sign the form by either typing your name or uploading a JPEG image of your signature. Save the completed form and send it by email to your manager.

Manager Approval

Print Name:	Click to enter text	Date Signed:	Select Date …
Signed:
Sign the form by either typing your name or uploading a JPEG image of your signature. Save the completed form and send it by email to People & Culture.