Child Safety Concern Form
Are you submitting this form as a child or a parent/guardian?
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General Details
Your Name
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First Name
Last Name
Phone Number
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Email
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example@example.com
Preferred Contact Method
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Phone,
Email,
In-person
No Contact Needed
Incident Details
Which activity or program are you or the child involved in?
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Tell us about your concern (What happened?)
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Who was involved? (if known)
When did it happen?
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Where did it happen?
How did this incident impact you or the child involved?
Explanations about emotional, physical, or psychological effects
What steps (if any) have been taken to address this so far?
Example: Spoke with a staff member, reported it to someone else, etc.
How would you like us to assist you?
Example: Investigation, follow-up, reassurance, safety measures
About You
What is your name?
First Name
Last Name
What did you do at our centre today?
Examples: Swimming lessons, Gym, Play, Other
Tell Us What Happened
How did it make you feel?
What happened?
Who was there?
Tell us their name if you know
When did it happen?
Today, Yesterday, When?
Where did it happen?
What can we do to help you feel better?
Tell us how we can help
Submit
Should be Empty: