Codicote Tennis Club - Child protection: incident report form


Details of person making the report:

Name

Date

Title/Position

Organisation name

Contact numbers:

Mobile

Home

Work

Address



Email address


Details of child affected:

Name

Date of birth

Contact numbers:

(If same as for parent/guardian, use section below)

Mobile

Home

Work


Address
(If same as for parent/guardian, use section below)





Details of parent/guardian:

Name

Relationship to child

Contact numbers:
Mobile

Home

Work

Address




Details of adult of concern (person who complaint/concern is about):

Name

Date of birth

Contact numbers:

Mobile

Home

Work

Address







Please include a summary of the incident/concerns below. Please describe any action that has been taken already.

Relevant paperwork and additional sheets should be indicated in the boxes provided and sent to LTA Child Protection with this form.


Number of additional sheets attached:

Other agencies/organisations/individuals informed:

Contact 1 Name and address of organisation/individual




Telephone number

Contact person/reference number

Contact 2 Name and address of organisation/individual



Telephone number

Contact person/reference number



When you have completed the form:
Attach any background documents and send the form to the LTA Child Protection Department by email or post.
Remember to telephone the Child Protection Department directly if you need advice quickly.
If you believe that someone may be at immediate risk, you should contact your local police or social services department. Dial 999 if there is an emergency.
Apart from the police or social services, you should not discuss this referral with anyone before taking advice from your county or LTA Child Protection officer.


LTA Child Protection
T: 0208 487 7008/7116
M (24 hour): 07971 141 024
F: 0208 487 7301
E: childprotection@lta.org.uk
www.LTA.org.uk/childprotection