SAFEGUARDING Report a Concern. If a child or an adult is at risk of immediate harm the police should be contacted. Person registering a concern (your name) * First Name Last Name What is your connection to Central Vineyard? * Staff Member Volunteer Church Member Member of the Public Date * MM DD YYYY Email * Contact Phone Number * (###) ### #### Tell us who or what it is you have a concern about... Child/Adult's Name (Their Name) * First Name Last Name Date of Birth If known MM DD YYYY Address Please provide the address of the person if you know it Ministry Area/Group * If the ministry area is not listed please select 'Other' and enter that in the space below. Kids & Youth General/Adults Other Other Ministry Area/Group Tell us about the concern or incident What is the concern or incident and why do you think it needs action * What is the concern or incident and why do you think it needs action When did it take place? * MM DD YYYY Time Hour Minute Second AM PM Where did it take place? * Who saw and reported it? * Action taken including who else has been informed I confirm that the information I have included in this form is, to the best of my knowledge, accurate and I hereby give permission for Central Vineyard to make contact with me on the number provided if further clarification about this incident is required. * I Confirm I have read, understand and accept your data and privacy policy * I Confirm Thank you for completing the form. We will review and be in touch as soon as possible. If a child or an adult with care and support needs is at risk of immediate harm the police should be contacted. Please read our data and privacy policy
