YMCA of Corsicana - Speak Up Form
Tell Us What Happened. You can use this form to tell us if something made you feel unsafe, uncomfortable, or worried. You will NOT get in trouble for filling this out. You can leave your name blank if you want.
Name
First Name
Last Name
Age
Program/Area
What Happened?
*
Where did it happen?
*
Gym
Pool
Classroom
Locker Room
Outside
Other
When did it happen?
Date
*
-
Month
-
Day
Year
Date
Time
*
Hour Minutes
AM
PM
AM/PM Option
Who was involved?
*
Did anyone see what happened?
*
Yes
No
Not Sure
If yes, who?
How did it make you feel?
Scared
Sad
Confused
Hurt
Angry
What would you like us to do? (How can we help?)
*
Is someone in danger right now?
*
Yes
No
Not Sure
Would you like us to talk to you?
*
Yes
No
If yes, how can we reach you?
Our Promise to You
We will listen to you. We will take this seriously. We will work to keep people safe.
Submit
Should be Empty: