Safe Church Concerns Form
First Name
Last Name
Mobile Number
Email Address
Name of Additional Witness (Full Name)
Phone Number for Additional Witness
Name of Team Leader you notified (Full Name)
Date and Time of Incident/Concern
Ministry Area of Concern (eg Kids, Youth, Sunday Service etc)
Name of person the report is in relation to (Full Name)
Age of person the report is in relation to (If unknow, please include and approximate)
Describe the Concern/Incident - What was observed, what was said, what action was taken? (Please provide as much factual information as possible)
Where any photos or videos captured of the concern/incident? (please email them to safety@vlg.church)
Yes
No
Was first Aid required? If so what action was taken?
Are there any first aid materials that need to be replaced?
Submit