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Our Greatest Health Issues
2038
Lessons from the Flu Epidemic of 1918: The Dangers of Using Fever Suppressing Drugs for Viral Infections
1975
Devastating Outcomes in Pregnant and Lactating Women Following Experimental COVID Vaccines
1798
April 16th VAERS Data Show Reports of Blood Clotting
1917
Blood Clots and Reports of Blindness Following Experimental COVID Vaccines
1806
J&J Vaccine Paused; Meeting Materials about Serious Adverse Events Unavailable
1589
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VOLUNTEER SURVEY
Name
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Email
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The phone number provided is my:
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Mobile
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Street Address
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City
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Afghanistan
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Virgin Islands, U.S.
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Country
What part of California do you live in:
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No. CA
Central CA
So. CA
What is Your Profession? Title?
Select the skills, talents or experience in an area you would like to assist. (select all that apply):
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Event planning
Fundraising efforts
Social media
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Project manager
Phone skills / people person
Market and/or Scientific Research
Influencer or connected to one
Volunteer coordinator
Legal
Tech support: CRM, Programming, Building Networking, Website Development and Email Campaigns
Writer / PR
Media: Photography, Editing, Videography
Approximately how many hours per week are you able to contribute to CHD California Chapter? Are there specific hours a day that you are available?
Please provide any other information that may be helpful (optional)
Please list 2 References that we may contact: (Name, Phone, Email, How they know you?)
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CLOSE
ATTORNEY INQUIRY
SECTION A
CONTACT INFORMATION / GENERAL INFORMATION
WHO HAS A LEGAL CONCERN?
*
SELF
MY CHILD
HOW MANY CHILDREN?
I AM A CONCERNED (CHECK ALL THAT APPLY)
Select All
PARENT
TEACHER
SCIENTIST
ADMINISTRATOR
HEALTH PRACTITIONER
GRANDPARENT
OTHER
WHAT IS YOUR CONCERN (CHECK ALL THAT APPLY)
Select All
VACCINE MANDATE
MASK MANDATE
PCR TEST MANDATE
VACCINE INJURY
FULL LEGAL NAME
*
First
Middle
Last
PHONE
*
EMAIL
*
ADDRESS
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
COUNTY
HAVE YOU SPOKEN WITH OR HIRED A LAWYER BEFORE ON THIS ISSUE?
*
NO
YES
SECTION B
In order to help us find you an attorney for your concern we need a little more information. We cannot guarantee that there will be an attorney willing to take on your case, but if you are accepted as a plaintiff the individual lawyer working with you will request additional information and documentation.
IF THIS CONCERNS A CHILD, ARE YOU THE LEGAL GUARDIAN?
NO
YES
N/A
DO YOU HAVE A COPY OF THE “MANDATE” LANGUAGE IF IN WRITING?
NO
YES
N/A
IF IN WRITING, PLEASE UPLOAD A COPY OF THE WRITTEN MANDATE
Drop files here or
DO YOU HAVE A RELIGIOUS OR MEDICAL OBJECTION TO THE MANDATE?
NO
YES
IF YES, HAVE YOU BEEN OFFERED A REASONABLE ACCOMMODATION (WORK FROM HOME, CHANGE OF POSITION, ETC.)
NO
YES
WAS THE ACCOMODATION OFFERED IN WRITING?
NO
YES
IF IN WRITING, PLEASE UPLOAD A COPY OF THE ACCOMODATION
Drop files here or
DO YOU HAVE A WRITTEN LEGAL EXEMPTION?
NO
YES
DO YOU KNOW OTHER PARENTS AT YOUR SCHOOL OR IN YOUR DISTRICT WHO ARE ALSO CONCERNED ABOUT THIS MANDATE?
NO
YES
WOULD YOU BE INTERESTED IN REFERRING THESE PARENTS TO OUR ORGANIZATION FOR SUPPORT?
NO
YES
IF YES, PLEASE PROVIDE CONTACT NAME
First
Last
PHONE
EMAIL
DOES THIS EMPLOYER/SCHOOL PROVIDE JAB-AND/OR PCR TESTING ON SITE?
NO
YES
ARE CERTIFIED MEDICAL PRACTITIONERS PERFORMING THESE TESTS /JABS?
NO
YES
Not Sure
IS YOUR CHILD’S HEALTH COMPROMISED DUE TO WEARING A MASK, PCR TESTED, JABBED?
NO
YES
Not Sure
IF YES, CHECK ALL THAT APPLY:
BREATHING PROBLEMS
HEADACHES
COGNITIVE PROBLEMS
SKIN IRRITATIONS
EMOTIONAL TRAUMA
MENTAL TRAUMA
BEHAVIOR PROBLEMS
PEER PRESSURE TO COMPLY
ADMINISTRATION PRESSURE TO COMPLY
LEARNING DECLINE
HAVE YOU SEEN A MEDICAL PROFESSIONAL?
NO
YES
IF YES, PLEASE PROVIDE NAME OF PRACTICE
NAME OF DOCTOR
First
Last
ADDRESS OF DOCTOR OFFICE
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
PHONE
EMAIL
WEBSITE
PLEASE PROVIDE DETAILS OF YOUR DOCTOR VISIT
Section C
ADDITIONAL INFORMATION
HAVE YOU TAKEN ACTION ON THIS ISSUE BEFORE?
NO
YES
IF SO, WHAT ACTION?
WROTE LETTER
MET WITH OFFICIALS
SPOKE AT MEETING
ATTENDED RALLY
MADE PHONE CALLS
ORGANIZED EVENT
OTHER
WOULD YOU BE WILLING TO BE NAMED IN SUIT?
NO
YES
ARE YOU WILLING TO WALK YOUR CHILD TO THE CLASSROOM AND TELL THE TEACHER THAT YOU WANT YOUR CHILD TO ATTEND ALL ACTIVITIES IN SCHOOL WITHOUT THE USE OF 1) ANY MASK OR FACE COVERING OR 2) WITHOUT A MANDATED TEST OR 3) WITHOUT A VACCINE?
NO
YES
ARE YOU WILLING TO TAKE PHOTOS/VIDEOS AND DOCUMENT THE EXPERIENCE AND REPORT IT BACK TO CHILDREN’S HEALTH DEFENSE?
NO
YES
WILLING TO SIGN AN AFFIDAVIT ABOUT INCIDENT(S)?
NO
YES
WILLING TO SPEAK PUBLICLY ABOUT THIS?
NO
YES
HOW DID YOU LEARN ABOUT CHILDREN’S HEALTH DEFENSE?
FRIEND
RELATIVE
COLLEAGUE
OTHER
Email
This field is for validation purposes and should be left unchanged.
CLOSE
VACCINE INJURY
SECTION A
CONTACT INFORMATION / GENERAL INFORMATION
WHO HAS A LEGAL CONCERN?
*
SELF
MY CHILD
HOW MANY CHILDREN?
I AM A CONCERNED (CHECK ALL THAT APPLY)
Select All
PARENT
TEACHER
SCIENTIST
ADMINISTRATOR
HEALTH PRACTITIONER
GRANDPARENT
OTHER
WHAT IS YOUR CONCERN (CHECK ALL THAT APPLY)
Select All
VACCINE MANDATE
MASK MANDATE
PCR TEST MANDATE
VACCINE INJURY
FULL LEGAL NAME
*
First
Middle
Last
PHONE
*
EMAIL
*
ADDRESS
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
COUNTY
HAVE YOU SPOKEN WITH OR HIRED A LAWYER BEFORE ON THIS ISSUE?
*
NO
YES
SECTION B
VACCINE INJURY
ARE YOU OK? DO YOU NEED MEDICAL ATTENTION?
NO
YES
WHICH VACCINE MANUFACTURER?
MODERNA
PFIZER
J&J
ASTRAZENECA
OTHER
PLEASE PROVIDE DATE OF JAB
Date Format: MM slash DD slash YYYY
WHERE DID YOU RECEIVE THE JAB?
ADDRESS OF JAB LOCATION
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
REASON FOR VACCINATION?
EMPLOYER REQUEST
EMPLOYER MANDATE
SCHOOL REQUEST
SCHOOL MANDATE
PERSONAL CHOICE
Section C
School or Employer information. If personal choice, please skip to Section D
WHO IS EMPLOYER OR SCHOOL?
If school or employer, please continue. Otherwise, skip to section D
PLEASE PROVIDE ADDRESS OF SCHOOL OR EMPLOYER
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
NAME OF PERSON ENFORCING MANDATE
First
Last
PHONE
EMAIL
SECTION D
LEGAL INQUIRY
ARE YOU INTERESTED IN FILING A LAWSUIT?
NO
YES
IF NO, DO YOU NEED MORE INFORMATION?
NO
YES
WHAT INFORMATION? (CHECK ALL THAT APPLY):
Select All
MASK SCIENCE
VACCINE SCIENCE
PCR TEST SCIENCE
EMERGENCY USE AUTHORIZATIONS LAWS
CONSTITIONAL OR FEDERAL LAWS REGARDING MEDICAL CHOICE
CONSTITIONAL OR FEDERAL LAWS REGARDING LOCKDOWN SCIENCE
Phone
This field is for validation purposes and should be left unchanged.
CLOSE
EMPLOYER MANDATE
SECTION A
CONTACT INFORMATION / GENERAL INFORMATION
WHO HAS A LEGAL CONCERN?
*
SELF
MY CHILD
HOW MANY CHILDREN?
I AM A CONCERNED (CHECK ALL THAT APPLY)
Select All
PARENT
TEACHER
SCIENTIST
ADMINISTRATOR
HEALTH PRACTITIONER
GRANDPARENT
OTHER
WHAT IS YOUR CONCERN (CHECK ALL THAT APPLY)
Select All
VACCINE MANDATE
MASK MANDATE
PCR TEST MANDATE
VACCINE INJURY
FULL LEGAL NAME
*
First
Middle
Last
PHONE
*
EMAIL
*
ADDRESS
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
COUNTY
HAVE YOU SPOKEN WITH OR HIRED A LAWYER BEFORE ON THIS ISSUE?
*
NO
YES
SECTION B
EMPLOYER MANDATE
HAS YOUR EMPLOYMENT BEEN THREATENED?
*
NO
YES
IF “YES” HAS THE THREAT BEEN
Select All
VERBAL
IN WRITING
EMPLOYER NAME (COMPANY)
NAME OF PERSON ENFORCING MANDATE
First
Last
TITLE (SUPERVISOR / MANAGER)
ADDRESS OF EMPLOYER
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
PHONE
EMAIL
COUNTY
Email
This field is for validation purposes and should be left unchanged.
CLOSE
School Mandate
SECTION A
CONTACT INFORMATION / GENERAL INFORMATION
WHO HAS A LEGAL CONCERN?
*
SELF
MY CHILD
HOW MANY CHILDREN?
I AM A CONCERNED (CHECK ALL THAT APPLY)
Select All
PARENT
TEACHER
SCIENTIST
ADMINISTRATOR
HEALTH PRACTITIONER
GRANDPARENT
OTHER
WHAT IS YOUR CONCERN (CHECK ALL THAT APPLY)
Select All
VACCINE MANDATE
MASK MANDATE
PCR TEST MANDATE
VACCINE INJURY
FULL LEGAL NAME
*
First
Middle
Last
PHONE
*
EMAIL
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
COUNTY
HAVE YOU SPOKEN WITH OR HIRED A LAWYER BEFORE ON THIS ISSUE?
*
NO
YES
SECTION B
SCHOOL MANDATE
HAS YOUR CHILD’S ATTENDANCE IN SCHOOL BEEN THREATENED IF YOU DO NOT COMPLY?
NO
YES
IF “YES” HAS THE THREAT BEEN
Select All
VERBAL
IN WRITING
SCHOOL NAME
SCHOOL DISTRICT
TYPE OF SCHOOL
PUBLIC
PRIVATE
CHARTER
K-6
K-12
MIDDLE
HIGH SCHOOL
COLLEGE
OTHER
SUPERINTENDENT NAME
First
Last
SUPERINTENDENT ADDRESS
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Email
PRINCIPAL NAME
First
Last
SCHOOL ADDRESS
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
PHONE
EMAIL
COUNTY
Phone
This field is for validation purposes and should be left unchanged.
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