Monthly Contact Log 20

MONTHLY CONTACT LOG

ASSIST Representative: Please complete, sign and submit this form by the first Friday of the month for the previous month. Any questions, please contact Cathy Presnick: cathy@assistscholars.org or 860-668-5706. Thank you!

Student Name*

First Name

Last Name

School Name*

Host Family Name*

NONE if not applicable

Month of*

Monthly Student Meeting: (Please note areas of success; areas of concern)*

Host Family Monthly Update (if applicable) via phone, email or in person:*

Please indicate if the student will move to a new Host Family (if applicable). (Include name of Host Family and date of move.)*

Areas in which ASSIST can help and support you and the student:*

ASSIST Representative Information

Name*

First Name

Last Name

Email*

Signature*

[clear]

Use your mouse or finger to draw your signature above

Date*