Safe Church Concerns Form

Gymea Baptist Church: Safe Church Concerns Form

This form is to be completed for any Safe Church concern in accordance with the GBC Safe Church Policy and the Procedure fo Responding to Child Protection Concerns (p.28 of the GBC Safe Church Policy). Please do not discuss the concern with anyone other than the Safe Church Team or your Ministry Leader.

This documentation is to be kept in a locked filing cabinet and/or in secrue electronic format for at least 45 years (preferably 100 years) from the date of completion.

If there is an immediate danger, please contact police on 000.

Details of Person Completing Report

First Name

Last Name

Home Address

Home City

Home Postcode

Email Address

Phone Number

Relationship to the victim and/or the alleged person causing harm:

Role (Ministry role, Church attendee, Concerned Public)

Details of Alleged Victim (if applicable)

Full Name of Alleged Victim

Date of Birth of Alleged Victim

Approximate Age of Alleged Victim (if birthdate is unknown)

Address of Alleged Victim

Parent/guardian name and contact phone number of Alleged Victim

DETAILS OF THE PERSON AGAINST WHOM THE ALLEGATION HAS BEEN MADE (if applicable)

Full Name of person against whom the allegation has been made

Date of Birth (if known) or Approximate age of person against whom the allegation has been made

Home Address of person against whom the allegation has been made

Position/title of person against whom the allegation has been made (if applicable)

Is the person aware of the allegation?

Yes

Nature of the Allegation

Provide details of the allegations that were made known to you - what has been alleged, when it was alleged to have occurred, other relevant details.

Name and Contact details of Witnesses

Names and Contact Details of any other person with knowledge of the alleged abuse

Signature

CONSENT TO HOLD INFORMATION

I consent to the information contained in this application, including any subsequent pages/documents, to be kept by Gymea Baptist Church. I understand that this information will be kept in a confidential file.

By entering my name and the date below, I declare that:

- the information I have provided is true and correct to the best of my knowledge and belief

Signature

Date