MODEL ATHLETE COMPLAINT FORM
INSTRUCTIONS: To file a formal complaint, please fill out this form completely and submit it to the Athlete Welfare Advocate of our Club. If you need help completing the form, or want to discuss the issue before completing the complaint form, please contact either of our Athlete Welfare Advocates for a meeting:
Mary Doe, 444-444-4444
John Doe, 444-444-4432
Please know that the information you submit will be held in confidence until you meet with the Athlete Welfare Advocate to discuss the process that will be followed to investigate and resolve the situation. The athlete should feel free to invite his/her parents to attend this meeting. Or, the athlete may prefer to have this meeting before discussing the situation with his/her parents. Or, for any athlete under the age of 18, the athlete’s parent/guardian may complete this form. Please note that the athlete will never be required to confront the person accused. Upon request, the Club will keep the name of the athlete confidential, except when in doing so results in a danger to other athletes.
PART I: Person(s) Submitting the Complaint
Person completing this form________________________________________________________
Check One: ___ I am the athlete ___Athlete’s parent/guardian ___Athlete Welfare Advocate___Other
1. Athlete’s Name: ____________________________________________________________________
2. Athlete’s Address: __________________________________________________________________
3. Athlete’s Telephone # _______________________________
4. If you wish to have your parent(s), guardian(s), or another person attend a meeting with the Athlete Welfare Advocate, please provide the following information:
Telephone # ____________________________Relationship______________________________
Part II: The Complaint
5. Please describe the circumstances causing your complaint (give specific factual details, times, location, and name all individuals involved or who witnessed the situation).
6. What was the date of the circumstances causing your complaint? _______________
7. Explain how you have been harmed by this circumstance.
8. Please describe any efforts you have made to resolve your complaint informally and the responses to your efforts.
Date With Whom Did Describe Conversation
9. (OPTIONAL) Please describe the outcome or remedy you seek for this complaint.
Signature of Person Submitting Report_____________________________________________________
Signature of Athlete Welfare Advocate _____________________________________________________