Senior Community Football 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 WA Football Integrity Report Form covers matters relating to the following categories.

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

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

Please indicate if you wish to remain anonymous to parties external to the WA Football 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 WA Football Integrity Unit. (However please remember if you do not leave your name, we will be unable to contact you for further information). Yes No
Are you under the age of 18?

Are you under the age of 18? 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 Other

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

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

Which competition does the Incident relate to PFL - Perth Football League Sunday Football League Integrated - All abilities Football AFL Masters WA AFL 9's

Please select all responses that apply.
Please indicate the gender of the competition

Please indicate the gender of the competition Female Male

Please select all responses that apply.
Which club does the Incident relate to
Date of Incident
Time
At what location did this Incident occur
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
If YES please provide the Offence Report Number or where reported.
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 WA Football 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

Senior Community Football Competitions

Senior Community Football Competitions

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