Maltreatment & Discrimination Allegation Intake Form

Maltreatment & Discrimination Allegation Intake Form

St. Albert Minor Hockey Association
The Maltreatment & Discrimination Allegation Intake Form is intended to bring forward any allegations of Maltreatment, specifically of discrimination, including verbal taunts, insults or intimidation based on discriminatory grounds (race, national or ethnic origin, colour, religion, age, sex, sexual orientation, gender identity or expression, marital status, family status, genetic characteristics, disability or language).

Allegations received will be forwarded to the required parties to determine if a formal investigation needs to take place. Allegations that are substantiated through investigation will be considered for suspensions and/or sanctions.

By completing this form, you agree that St. Albert Minor Hockey may share the information contained here within with other parties or individuals in order to investigate the allegation brought forth.
NAME OF PERSON MAKING THE ALLEGATION (First, Last):

First NameLast Name
Phone Number:
Please enter a valid phone number.
Contact Email:
example@example.com
POSITION OF PERSON MAKING THE ALLEGATION:

PlayerParent/GuardianTeam OfficialOn-Ice OfficialOff-Ice OfficialMHA/Club Team RepresentativeLeague RepresentativeOther
NAME OF PERSON ON WHOSE BEHALF THE ALLEGATION IS MADE- IF APPLICABLE (First, Last):

First NameLast Name
Phone Number:
Please enter a valid phone number.
Email:
example@example.com
POSITION OF PERSON ON WHOSE BEHALF THE ALLEGATION IS MADE:

PlayerParent/GuardianTeam OfficialOn-Ice OfficialOff-Ice OfficialMHA/Club Team RepresentativeLeague RepresentativeOther
NAME OF PERSON ALLEGATION IS BEING MADE AGAINST (First, Last):

First NameLast Name
Title/Role (if applicable):
Phone Number:
Please enter a valid phone number.
Email:
example@example.com
POSITION OF PERSON ALLEGATION IS BEING MADE AGAINST::

PlayerParent/GuardianTeam OfficialOn-Ice OfficialOff-Ice OfficialMHA/Club Team RepresentativeLeague RepresentativeOther
NAME OF ADDITIONAL PERSONS ALLEGATION IS BEING MADE AGAINST (if applicable):
Title/Roll (if applicable):
Phone Number:
Please enter a valid phone number.
Email:
example@example.com
DATE OF OCCURENCE:

MonthDayYear
Date
PLEASE SELECT THE TYPE OF BEHAVIOUR:

Verbal Taunts/InsultsIntimidationConductGesturesOther
PLEASE SELECT THE TYPE OF MALTREATEMENT/DISCRIMINATION:

RaceNational or Ethnic GroupColourReligionRaceSexSexual OrientationGender Identity or ExpressionMarital StatusFamily StatusGenetic CharacteristicsDisabilityLanguageOther
WHERE DID THE PROPOSED INCIDENT TAKE PLACE:
WHO WAS INVOLVED:
DESCRIBE THE INCIDENT:
HOW WAS THE VICTIM TREATED DIFFERENTLY THAN OTHERS?
HOW DOES THE BEHAVIOR RELATE TO THE GROUNDS YOU SELECTED?
WHAT RESOLUTIONS ARE BEING SOUGHT?
PLEASE PROVIDE ANY OTHER INFORMATION YOU'D LIKE TO PROVIDE:
Should be Empty: