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School Intake Form

Your Information Full Name: Email: Phone:

School Information School or District Name: Address 1: Address 2: City: State: Zip: School District Affiliate Name: # of Schools in District: School District Funding for 2025/2026 Budget: Are you a member of an Insurance Pool, Joint Powers Authority, or similar? Yes No If Yes, Name: Do you have a "Banked Days Policy"? Yes No Paid Time Off (PTO) Allowance (avg# of days): Paid Sick Days Allowance (avg# of days): Maternity/Paternity/Adoption Policy (avg# of days):

Absence Data Number of FTE’s to be covered:

Please check all staff categories you wish to be covered:

Teaching Staff Administrators Office Staff Maintenance Staff Transportation Staff Safety/Security Staff Technology Nurses Other (please specify):

Current Coverage Information Please advise if you wish cover to be provided for: Paid Time Off (PTO) Unpaid Leave Banked Days

Absence Data Upload

Regarding the individuals for whom you require coverage, please provide 3 years of absence data including condition/reason for absence.

Please upload your data here:

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