ACTIVITY OUTING LOG
(AFFILIATED WITH BEHAVIORAL COUNSELING SERVICES, LLC)
FACILITY
*
SHOULDER HOUSE
YOUTH PARTICIPANTS
*
DATE
*
TIME OF DEPARTURE
*
AM or PM
*
AM
PM
ANTICIPATED TIME OF RETURN
*
AM or PM
*
AM
PM
STAFF NAME
*
DRIVER'S NAME
*
FORM OF TRANSPORTATION
VEHICLE
WALK/BIKE
BUS
TAXI
Other
VEHICLE INFORMATION
Please Select
2015 CHEVY EXPRESS 3500 VAN / VIN# 1GAZG1FG1F1170733/ AZ EXP: 18 Dec./ Plate #: CK04887
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
*
Submit
Should be Empty: