ACHIEVING BETTER COPING SKILLS LLC
YOUTH ACTIVITY OUTING LOG
FACILITY
*
ASHER HOUSE
YOUTH PARTICIPANTS
*
DATE
*
TIME OF DEPARTURE
*
AM or PM
*
AM
PM
ANTICIPATED TIME OF RETURN
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AM or PM
*
AM
PM
STAFF NAME
*
DRIVER"S NAME
*
DRIVER"S LICENSE NUMBER:
*
DRIVER"S LICENSE EXPIRATION DATE
*
FORM OF TRANSPORTATION
VEHICLE
WALK/BIKE
BUS
TAXI
Other
VEHICLE INFORMATION
Please Select
2016 CHEVY EXPRESS 3500 VAN / VIN# 1GAZGPFGXG1160867 / CK53121
2017 DODGE GRANDE CARAVAN / VIN# 2C4RDGEG2HR557827 / CES 6875
DESTINATION INFORMATION
NAME OF LOCATION:
*
STREET ADDRESS:
*
CITY:
*
STATE:
*
ZIP CODE:
*
PHONE:
*
NUMBER OF YOUTH:
*
NUMBER OF STAFF
*
BRIEF DESCRIPTION OF ACTIVITY:
*
LIST ALL PARTICIPATING NAMES
*
STAFF NAME
*
Staff Signature
*
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