OREGON Y0UTH CHALLENGE PROGRAM

23861 Dodds Road, Bend, OR  97701

Phone:541-317-9623  Fax: 541-382-6785

MENTOR MONTHLY REPORT  (due by the 20th of the month)
 

Casemanager Name
Mentor Name
Phone Number Email
Address: Street
City, State, Zip
Cadet Name
Cadet Phone Number Email
Cadet Address: Street
Cadet City, State, Zip


Type of Contact

Did you have at least 4 hours of contact with your Cadet? Yes No
Date     Specify Type(i.e. Email, Face to Face)
   
   
   
   
   


Post Residential Placement Activity

Please check all boxes that best describes what your Cadet has been doing during the reporting month. Please write the dates that he/she enrolled in school, enlisted in a military service/shipped, or began working including employer’s name and wage amount.

Education   Military Service   Miscellaneous
Return to HS Active Reserve Deceased
Vo Tech Army Moved out of State
College Navy Incarcerated
Job Corps Marines Arrest/Violations
Adult Education Air Force Disabled/Hospitalized
Coast Guard Unknown
National Guard
Enroll Date Enlist Date  
School Name Ship Date  
Counselor MOS  
           


Employment/Volunteer

Hire Date Company Position Wage Part Time Full Time
Termination Date Reason
Additional Information