Institute Safe Keeper Report Form

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Thank you making the safety of our teens a top priority! If you have a concern, suspicion, weird feeling, etc. about a staff member, volunteer, or another teen/adult relationship or teen/teen relationship, please complete the information below. The more details we have the better. No report is too small or too large.

Additionally, if you have heard a student mention that they have been hurt by someone, have harmed themselves or others, or are thinking of harming themselves or others, please complete the form. This form enables us to put together various pieces from reports to see if follow up is needed for any situation. Thank you for your support in keeping our teens safe!

Email *

Your Name *

Your name will not be shared to people beyond YMCA Staff unless you approve otherwise.

Name of the Staff/Volunteer/Adult prompting your report *

Put N/A if not applicable. Please remember that we will never use your name to discuss a concern with another person.

Name of Student/Participant prompting your report *

Put N/A if not applicable. Please remember that we will never use your name to discuss a concern with another person.

Name(s) of any additional Student/Participant(s) involved in incident

Please list and explain in detail your child safety concern in the box below *

Please let us know which session (including time of day) of our Institute the incident occurred in. *

Date of Safe Keeper Report *

YYYY

Is there additional information you want YMCA Staff to know?

Send me a copy of my responses.

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