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Chipstead Place Lawn Tennis Club

CPF 3.1.11 - Child protection: incident report form

 

Details of person making the report:

Name

 

 

Date

 

Title/Position

 

Organisation name

 

Contact numbers:

 

 

Mobile

 

 

Home

 

 

Work

 

 

Address

 

 

 

 

Email address

 

 

         

 

Details of child affected:

Name

 

 

Date of birth

 

Contact numbers:

(If same as for parent/guardian, use section below)

 

Mobile

 

 

Home

 

 

Work

 

 

Address

(If same as for parent/guardian, use section below)

 

 

 

 

         

 

Details of parent/guardian:

 

Name

 

 

Relationship to child

 

Contact numbers:

 

Mobile

 

 

Home

 

 

Work

 

 

Address

 

 

 

         

 

 

 

 

 

 

Details of adult of concern (person who complaint/concern is about):

 

Name

 

 

Date of birth

 

Contact numbers:

 

Mobile

 

 

Home

 

 

Work

 

 

Address

 

 

 

 

 

 

         

 

 

Please include a summary of the incident/concerns below. Please describe any action that has been taken already.

 

Relevant paperwork and additional sheets should be indicated in the boxes provided and sent to the CPLTC Child Protection Officer with this form.

 

Number of additional sheets attached:

 

 

 

 

 

 

 

Other agencies/organisations/individuals informed:

 

Contact 1

Name and address of organisation/individual

 

 

 

 

Telephone number

 

Contact person/reference number

 

Contact 2

Name and address of organisation/individual

 

 

 

 

Telephone number

 

Contact person/reference number

 

 

 

 

When you have completed the form:

Attach any background documents and send the form to the CPLTC Child Protection Officer by email or post.

If you believe that someone may be at immediate risk, you should contact your local police or social services department. Dial 999 if there is an emergency.

Apart from the police or social services, you should not discuss this referral with anyone before taking advice from your club’s Child Protection officer.

 

 

 

CPLTC Child Protection Officer

Magdalen Fry

T: 01732 462351

M: 07799 137942

E:

 

 

 

 

LTA Child Protection

T: 0208 487 7008/7116

M (24 hour): 07971 141 024

F: 0208 487 7301

E:

www.LTA.org.uk/childprotection

 

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