Country Football WA (Senior & Junior Competitions)

Please note: If this matter is urgent or requires immediate assistance - please call Emergency Services on 000 or Crimestoppers on 1800 333 000

This WAFC Integrity Report Form covers matters relating to the following categories.

• Child Safe Guarding
• Grooming
• Illicit Substances
• Sexual Misconduct
• Wagering
• Anti Doping
• Match Fixing

All other competition and program matters must be directed to your Club, League or your Country Football WA Regional Specialist in the first instance.

By completing and submitting the following information the WAFC Integrity Unit will be notified and contact you accordingly.

Please indicate if you wish to remain anonymous to parties external to the WAFC Integrity Unit. (However please remember if you do not leave your name, we will be unable to contact you for further information).

Please indicate if you wish to remain anonymous to parties external to the WAFC Integrity Unit. (However please remember if you do not leave your name, we will be unable to contact you for further information). Yes No
Please Enter Your Details
Your Name Your Name First Last
Your Role

Are you a Player, Coach, Team Official, Parent, Spectator?
Your Phone Number
Your Email
What is the nature of the Incident

What is the nature of the Incident Child Safe Guarding Grooming Illicit Substances Sexual Misconduct Wagering Anti Doping Match Fixing

Please select all responses that apply.
Who does the Incident involve

Who does the Incident involve Player Spectator Club Official Coach Umpire League Official Parent Trainer County Football WA Staff

Please select all responses that apply.
Which area does the Incident relate to

Which area does the Incident relate to Senior Football - Male Senior Football - Female Junior Football
Which club does the Incident relate to
Date of Incident
Time
At what location did this Incident occur

Specific locality of incident
Brief Description of Incident

Please provide a brief summary of the incident.
Has the matter been reported to the Police

Has the matter been reported to the Police Yes No Unsure

Has the incident been Reported to Police
Upload a File or supporting document if relevant

Attach Files

A supporting file or photograph may be attached.
The information I have provided in this Statement is true and correct to the best of my knowledge and represents everything I can recall. I understand that this Statement may be used to assist the WAFC Integrity Unit report on how a matter may proceed and that it may be provided to other relevant parties.

By submitting this form I acknowledge the above statement

Country Football WA (Senior & Junior Competitions)

Country Football WA (Senior & Junior Competitions)

Please Enter Your Details