Visit Report

Reimbursement agreement: *

I understand that I must submit a detailed reimbursement form and original receipts to receive reimbursement.

Food/Activity Costs: *

Were there any issues with the caregivers? If yes, please explain. *

Were there any issues between mentee and mentor during the visit? If yes, please explain. *

Description of Activities: *

Did you have a break-through story that you would like to share? If retold, identifying information will be changed. *

Were there any general issues or problems during the visit? If yes, please explain. *

Please explain your rating - what made this visit so good or bad? *

Pick-up Time: *

Date of Visit: *

Mentee (first name only): *

Odometer at pick-up: *

Drop-off Time: *

Are there any changes in the mentee's living situation? If yes, please explain. *

Odometer at drop-off: *

Mentor Name: *

Teen Reach Adventure Camp