Safeguarding reporting form

Canoe Sports Trust
Safeguarding reporting form
This form must be completed and submitted within 24 hours of the safegaurading incident. You should already have spoken to the Canoe Sports Trust's Welfare Officer (Julia Pich).
Name of person reported to
Date reported

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Your information
Name
Address
Contact number
Email
example@example.com
Personal information - child / young person
Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender

Other
Is there any information about the child that would be useful to consider?
Contact information - parent / carer
Name(s)
Address
Contact number
Email
example@example.com
Have they been notified of this incident?
February 2026 | Page 1 of 3

Safeguarding concerns*
Date and time of incident
Please tick one:
Name of person raising concern
Role within the sport/activity or relationship to the child
Contact number
Email
example@example.com
Details of the incident or concerns (Include information such as times, dates, description of any injuries and if any other parties were involved, and whether you are recording this incident as fact, opinion or hearsay. Also include any other relevant information known about the family's/child's circumstances.)
Child's account of the incident
Please provide any witness accounts of the incident.
Name of witness (and date of birth, if a child)
Role within the sport/activity or relationship to the child
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact number
Email
example@example.com
Name (and date of birth, if a child)
Role within the sport/activity or relationship to the child
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact number
Email
example@example.com
Please provide details of action taken to date
* Attach a separate sheet if more space is required (e.g. multiple witnesses)
February 2026 | Page 2 of 3

Canoe Sports Trust
Safeguarding reporting form
Incident details (continued)
Has the incident been reported to any external agencies?(e.g.police, LADO, social services, NSPCC, etc)
Name of organisation / agency
Contact person
Contact number
Email
example@example.com
Agreed action or advice given
Declaration
Your signature
Print name
Today's date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
February 2026 | Page 3 of 3
Should be Empty: