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Monthly Activity Summary: Youth 5-17
Summaries are due on the 10th of each month
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
2016
2017
2018
Your Name
Child's Name
Date of Visits
Hours
Description of Event/Activity
Comments/Positive Experiences
Challenges/Concerns
Provide any updates to the following information:
DCS Case Manager
Child's Contact at Residence
Residence of Child
Child's Phone Number