Mentor and Corpsmember’s Information

Mentor’s Name:

Mentor’s Phone Number:

Corpsmember’s Name:

Corpsmember’s Phone Number:

Corpsmember’s Mailing Address:

Please provide (in the section below) when and how contacts were accomplished.

Date of Mentor Contact:

Type of Contact  (Phone, Face-to-Face, Letter, Email, Other:

Date of Mentor Contact:

Type of Contact  (Phone, Face-to-Face, Letter, Email, Other:

Date of Mentor Contact:

Type of Contact  (Phone, Face-to-Face, Letter, Email, Other:

Date of Mentor Contact:

Type of Contact  (Phone, Face-to-Face, Letter, Email, Other:

Post Residential Placement Activity

Education:

Vo Tech:

College:

Job Corps:

Adult Ed:

No Continuing Education:

Military Service:

Active Military:

Reserves:

National Guard:

AGR:

No Military Service:

Miscellaneous:

Deceased:

Moved out of State:

Incarcerated:

Living in State:

Law Violations:

Disabled/Hospitalized:

Employment:

Part Time Job:

Employer:

Hourly Wage:

Part Time Job:

Employer:

Hourly Wage:

Full Time Job:

Employer:

Hourly Wage:

Volunteer:

Employer:

Caregiver:

Employer:

Hourly Wage:

Apprenticeship:

Employer:

Hourly Wage:

Self-employed:

Employer:

Hourly Wage:

Homemaker:

Seeking employment:

Not employed:

Any additional remarks you would like passed along to the staff?

Once you click submit, your information will be electronically submitted to one of the NMYCA staff for processing. Thanks again for all your help.