Email (required) *

Month: *

Mentor’s Name: *

Student’s Name: *

School:

Grade:

Teacher:

Do you have a normal visitation time with Mentee, if so when? *

FAMILY CONTACT, communication, call or text with Family/Caregiver Total time with Family or Caregiver: *

DIRECT SERVICE (with mentee at school) Description of Activities (briefly describe session with the mentee): *

Total Time Spent as a Mentor this month: *

We would like to know the personal progress of your Mentee, are they struggling in school, are they excelling, Parent or Caregiver contact, Teacher contact, anything significant happening that we may be able to assist by recommending services, etc. Please comment below.

Is there anything we can do for you? (supplies, support etc.)