Report a Concern
This form is part of the Complaints, Disputes and Discipline Policy. The information provided in this complaint form will be handled in accordance with the Water Polo Australia Privacy Policy.
About you
Your Name
*
First Name
Last Name
Your Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Your state
*
Please Select
ACT
NSW
QLD
SA
NT
VIC
WA
TAS
Are you over 18?
*
Yes
No
What is your role in Water Polo?
*
Administrator
Athlete
Parent
Spectator
Referee
Board/Committee Member
Coach/Assistant Coach
Employee
Volunteer
The complaint
Nature of your complaint
*
Please Select
Personal Grievance
Social Media breach
Code of Conduct breach
Other
Please note complaints in relation to Integrity-related policies must be submitted directly to Sport Integrity Australia. Find out more here - https://www.waterpoloaustralia.com.au/info-hub/integrity/
Which Policy has been breached? (You must select at least one)
*
Member Protection Policy
Improper Use of Drugs and Medicine Policy
Child Safeguarding Policy
Competition Manipulation and Sport Wagering Policy
WPA Code of Conduct
WPA Selection Policy
WPA National Age Group Selection Policy
WPA Social Media Policy
WPA Personal Grievance Policy
What section of the Policy has been breached?
*
Date of incident
*
-
Day
-
Month
Year
Date
Details and/or description of the person you are complaining about
*
Include Full Name, Position and any other relevant information that will assist in identifying the person.
What happened?
*
Please provide as much information as possible including details of who was involved, describe what happened and when (time/date), where and how you found out about the breach.
What level of the sport did this incident occur?
*
Please Select
International
National
State
Club
Not sure
Are there any witnesses to this incident?
*
Yes
No
Witness Name
First Name
Last Name
Witness email address
example@example.com
Witness phone number
Please enter a valid phone number.
Add another witness
Yes
No
Witness Name
First Name
Last Name
Witness email address
example@example.com
Witness phone number
Please enter a valid phone number.
Do you have any files to share at this time?
Browse Files
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Choose a file
This could be screen shots, email exchanges or anything relevant to the management of the complaint.
Cancel
of
If appropriate, would you consent to mediation with the Respondent?
*
Yes
No
Declaration
Please verify that you are human
*
Submit
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