PREMIER LEAGUE

APPENDICES PREMIER LEAGUE FORMS
PREMIER LEAGUE
NOTIFICATION OF REFERRAL (Rule S.25)
To: The Head of Safeguarding, The Premier League
And to: The Head of Education and Child Protection, The Football Association
We, Football Club, hereby notify you that a referral has been made
to the police or to Social Services in respect of a Child involved in an Activity. Particulars are as follows:
The Child
Full name Address
Post Code Date of birth
The Activity
Nature of the Activity Date Time
Place
The allegation or incident referred
The police
Date and time of referral Police force
Address Telephone
Name and rank of officer
Summary of advice received
Social Services
Date and time of referral Local authority name
Address Telephone
Name and designation of officer
Summary of advice received
ISA and/or County Safeguarding Lead
Date and time of referral Local authority name
Address Telephone
Name and designation of officer
Summary of advice received
250
Signed
Position
Date
Form 23