Safety Incident Report Form (Dance Church)
This form is the place to submit reports on safety/consent/boundaries incidents for review by the Dance Church Safety & Care Team. All responses and personal information will be kept confidential within the Safety & Care Team. A member of the Safety & Care team will follow up with you as soon as possible.

You may fill this out on behalf of yourself or another person, or have a trusted advocate fill this form out on your behalf. You may also have them be our point of contact, if so, please fill out their information in the form below.

After understanding all information and consulting appropriate resources, the team will develop and implement the best possible response measures to protect dancer safety.

Thank you for taking the time to report this incident.

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How you want this information to be used and/or protected?
 *
Date of incident *
MM
/
DD
/
YYYY
Your name (or alias) *
Your email address
Your phone number
Are you submitting this on behalf of yourself or another? *
If submitting this for another person, are you acting as the trusted advocate for this person? *
Who are the appropriate people for the Safety & Care Team to contact? If different from listed, please record contact info here. *
When is the best time for the Safety & Care Team to respond? *
Please describe the incident in as much detail as possible. *
Name of the person who acted unsafely or crossed boundaries.
Do you want to be involved in a conversation with the person involved AND a Safety and Boundaries Team member to mediate this issue?
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Is there anything else you'd like to mention?
How can Dance Church best support you through this process?
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