Leave Request Form

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Leave Request Form

Instructions: Please complete this form thoroughly. All requests should be submitted a minimum of 2 weeks prior to your departure date. Once submitted, you request will be reviewed by the team at our next staffing (held every Thursday). After staffing, you will receive an update on the status of your request.

Please note that if you have had a violation that occurred in the past 30 days prior to the date you are asking to leave, your leave request may be denied. You may still submit the request for review, however, if you feel there are circumstances that merit the leave being approved despite your recent violation.

Please note that if you are behind on payments and have not yet set up a payment plan, your request may be denied. To review your financial situation and develop a payment plan, please call Destin at 762-400-6874.

If you have any questions about the information requested below or would like help completing the form, please call the DUI Treatment Court office at 706-613-3206.

Email *

Please list your full name below: *

Please provide your current home address and the best contact number below: *

Please list the date of your departure below: *

YYYY

Please list the time of your departure below: *

Time

Please list the date of your return below: *

YYYY

Please list the time of your return below: *

Time

Please list where you are asking to go below. If you have a physical address, please provide it. *

You will be required to provide specific information about where you are going. Please gather those details before submitting this form.

Please list what the trip is for and why it is important to you below: *

Please list any program obligations you know you will miss if your leave request is approved. Please provide the type of obligation and the date. *

Ex: drug screens when my color is called, individual counseling, group, status conference, etc.

Are you up to date on a payment plan or do you make a monthly payment in full? If yes, please provide the last date and amount of payment. If no, please explain why. *

If your past due balance is more than $500 or you are not up to date on a payment plan, your request may be denied. If you have not made a payment so far and have not discussed your financial situation with your probation officer and the DUI Treatment Court office, please do so for further guidance.

If you have any questions or comments you would like to provide to the team during review of your request, please provide them below. If none, write none below. *

Send me a copy of my responses.

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