Date: 
Start and Finish Time of Session:
Location of Session: 
Mentor Name (first and last): 
Mentee Name and Student ID Number: 
What was discussed during the session (referrals, careers, transfer, personal experiences, student encouragement, etc.)?

Check the appropriate boxes that reflect what you did during the session.










If other, please describe:

If you provided academic support/tutoring, please list the class(es) you focused on: