SafeGuarding Form

Alloa Elim Pentecostal Church

Referral Form

Details of Person at Risk

First Name

Last Name

Main Contact Details

Landline Phone

Mobile Phone

Person Details

Date Of Birth

Age

Gender

Male

Female

Not essential

Ethnicity

Address

Address Line 1

Address Line 2

Town/City

County

Postcode

Country

Church

First Name

Last Name

Parent/Guardian Address

Same as Above

Different Address

Address

Address Line 1

Address Line 2

Town/City

County

Postcode

Country

Details of Person Completing Referral

First Name

Last Name

Phone Number

Address

Address Line 1

Address Line 2

Town/City

County

Postcode

Country

Relationship Type to Person at Risk:

Position in Church:

Details of the person involved in the Allegation

First Name

Last Name

Gender

Male

Female

Not essential

Address

Address Line 1

Address Line 2

Town/City

County

Postcode

Country

Relationship Type to person at risk

Additional Notes you would like to add

Details of the Allegation

Date / Time of Allegation

Location

Details of incident

Actions taken in relation to allegation

Name of safeguarding lead (if known)

Advice sought/notification to Social Services and/or police

What Now

Following this referral, the information contained within will be sent through to Elim’s National Safeguarding Team. Please print a copy of this form for your own records.

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SafeGuarding Form

Details of Person at Risk

Main Contact Details

Person Details

Details of Person Completing Referral

Details of the person involved in the Allegation

Details of the Allegation

What Now

Following this referral, the information contained within will be sent through to Elim’s National Safeguarding Team. Please print a copy of this form for your own records.

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