Grand Area Mentoring

1. Mentor name:

2. Mentor Email:

3. Mentee name:

4. Activity Date (month/day/year ex: 05/16/2018):

5. Start Time:

6. End Time:

7. Location: (Use Ctrl-Click to choose multiple locations)
-- Please Select --* Grand County School District campusGrand County Public LibraryKZMU* Moab area business, educational institution, or organization* Moab area restaurant* Moab area hiking trail* Moab area storeMoab Arts and Recreation Center* Moab City parkMoab Information CenterMoab Recreation and Aquatic Center* Official Grand Area Mentoring-sponsored activityThe Museum of Moab* National Park* State ParkUtah Department of Workforce ServiceWabiSabiYouth Garden Project* Other

8. If your selection has an asterisk(*), please input the specific site (for example, which school or trail):

9. If you did NOT meet at an approved site, did you have written permission from your mentee’s parent AND permission from the program director?
YesNo

10. Please record notes and a brief description of activity (including a summary of your meeting, relevant behavioral observations, details about who else was present, or plans for the future):