Safeguarding Referral Form

Information included in this report will form part of England Lacrosse’s investigation into the alleged incident.

As the person completing the referral, it is your responsibility to tell anybody whose details you include on this form that their information might be shared with other organisations and individuals relevant to the investigation.

Remember to maintain confidentiality and do not discuss this incident with anybody other than those who need to know.

About You

Your organisation/ club

Position in club/ organisation

Name

First Name

Last Name

Contact Telephone Number

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

About the Concern

Date of Concern or Incident

YYYY

Please give a brief description of the incident or concern (including dates, times, venues etc)

Have you spoken to the young person(s) in question? If so, please provide details

What is the relationship between the young person and the accused?

Details of the Young Person(s)

Name

First Name

Last Name

Gender

Date of Birth

YYYY

Parent/ Legal Guardian Name

First Name

Last Name

Contact Telephone Number

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Actions Taken So Far

Have you spoken to the parent/carer of the young person involved?

If you are the parent or carer of the young person involved, please select 'yes'

Yes

Please outline any actions or discussions which have taken place so far

Have you contacted any of the following external agencies?

England Lacrosse

Police

Children's Social Care

Other (eg. NSPCC)

If so, when did you make contact?

YYYY

Who did you speak with?

Please provide any additional details, report numbers, or advice received

Any Other Information

Please include any additional supporting information here