Please complete this form after every youth/adult partnership activity.

Contact Person 

County             

Region             

Location           

Date                 

Participants:  Youth      Adults

   White, not of Hispanic Origin       Black, not of Hispanic Origin    Native American/ Alaskan Native

   Asian or Pacific Islander              Hispanic                                    Mixed

   Female               Male  

What kind of function? Select Training Communtiy Service Activity Speaking Engagement Community Event

If this was a Community Event, Please Specify.

1. Duration of the Activity (in Hours)      

2. How will they use the skills/knowledge gained through this training?

3. Did you partner with other oganizations?    Select Yes No   

If so, please briefly Explain

4. Any Additional Comments?

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