Whitney Young AcademyMentor Hours & Engagement FormThank you for your commitment to your youth!Keep us up to date on all of the amazing things you’re doing with your mentee(s)! "*" indicates required fields URLThis field is for validation purposes and should be left unchanged.MentorMentor Full Name* First Last Mentor Email* Mentee(s)Mentee Full Name* First Last 2nd Mentee? Yes No 2nd Mentee Full Name* First Last 3rd Mentee? Yes No 3rd Mentee Full Name* First Last 4th Mentee? Yes No 4th Mentee Full Name* First Last Add any additional names needed in the Activity description box below.ActivityLocation of Activity* Location City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Date of Activity* MM slash DD slash YYYY Time Spent* 30 Minutes 1 Hour 1.5 Hours 2 Hours 2.5 Hours 3 Hours 4 Hours Other Activity Type*Describe what you did with your mentee(s) and provide details about the experience. Please remember to maintain the trust of your mentee(s) by sharing information pertinent to this activity or the youth's development. However, also note that Nebraska is a mandatory reporting State. If there was information shared with you that is cause for concern regarding the youth's safety, you are required to notify us immediately. Questions?Contact Brandy Clements at [email protected] with any comments or questions.
