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COUNTY YMCA
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Community Care & Safety Feedback Form
Community Care & Safety Feedback Form
We are committed to maintaining a safe, respectful, and supportive environment for all children in our programs and facilities. This form allows you to confidentially share concerns, observations, feedback, suspected policy violations, inappropriate behavior, or potential safety issues directly with Senior Leadership for review.
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Type of Grievance (Select all that apply)
*
Child on Adult Conflict
Child on Child Conflict
Bullying or Harrassment
Discrimination or Bias
Supervisor/Management Concern
Unsafe Environment
Other
Please describe the concern or grievance (Include what happened, when it occurred and any relevant details you feel comfortable sharing)
*
Has this issue happened more than once?
*
Yes
No
Not Sure
user (Short Have
Have you reported this issue to anyone before?
*
Yes - To a staff member
Yes - To Leadership
No
Yes - Other (please explain)
Would you be open to being contacted for follow-up?
*
Yes, and I'll provide my name and contact below
No, I prefer to remain anonymous
Optional: Name & email or phone number (Short Answer (Conditional if user selects Yes above))
Submit