Name *

First Name

Last Name

Is the person aware of this report?

Yes

No

Is the parent/guardian aware of this report? (where applicable)

Yes

No

Child Protection Concern:

Observed/ Suspected by yourself

Disclosure by the person

Allegation made by

Who is the person subject of the allegation/information?

Church Staff

Church Volunteer/ Leader

Family member of child

Member of Congregation

Someone in the community