Your contact details

Full name*

Contact number*

Email address*

Incident details

Date*

Time*

Venue*

Description*

Additional information

Are you a registered member of Water Polo Queensland?

yes

no

Name of person complained about (Respondent)

Level of the Sport at which alleged breach occurred?

NSO level where they relate to behaviour an incident or circumstances that occurred at or involve individuals operating at the NSO level

State Member level where they relate to behaviour an incident or circumstances that occurred at or involve individuals operating at the State Member level; or

Affiliate Member level - where it relates to behaviour an incident or circumstances that occurred at or involve individuals operating at the Affiliate Member level (Association/League/Club level)

Did anyone else witness this alleged breach by the Respondent?

yes

no

not sure

Does Complainant consent to alternative dispute resolution?

yes

no

Age Group

Gender

White Caps

Blue Caps

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