Mentor Full Name
Mentee Full Name
Contact Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age of Child
Sex of Child
Female
Male
Items Provided to the Mentee
School supplies, clothes, diapers, etc
Highlights from the Session
Accomplishments of the Mentee
Any comments or questions you might have at this time regarding mentorship
Does your mentee have a library card?
Yes
NO
Please report the total amount of time spent with mentee-in person/phone/facetime.
Please report the number of books your mentee read to her baby this month.
Did you provide additional items or money to mentor? Please be specific with dollar amount.
Have you noticed that your mentee has improved self-confidence or self esteem?
No
Yes
If Yes, give example of improved self esteem.
Please report how your mentee is doing with her school classes. Updates on grades, improvements, challenges, need for a tutor, etc.
Date report submitted
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: