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MANDATES AND INJURIES
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CA Defender News
“The greatest crisis that America faces today is the chronic disease epidemic in America’s children.” - Robert F. Kennedy, Jr.
CA SB 742 Criminalizes Peaceful Protests
Culver City USD Gets a Cease-and-Desist Letter Over Illegal Vaccine Mandate
Peaceful Protest in Santa Monica Shows the Power of People
“No Vaccine Passport Rally” in Santa Monica
CA SB 742 Attacks Free Speech and the Right to Assemble
The Endless State of Emergency Must End to Restore our Rights
Read More
Exposing Causes
“The way you get democracy to function is by informing the public.”
– Robert Kennedy
Too Many Sick Children
Known Culprits
False Narratives
Vaccine Safety Project
Restore Child Health
Research Database
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VOLUNTEER SURVEY
First and Last Name
*
First
Last
Email
*
Phone
*
The phone number provided is my:
*
Mobile
Home
Work
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Which County Do You Live In?
What part of California do you live in:
*
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):
*
Select All
Event planning
Fundraising efforts
Social media
Marketing content provider
Graphic Designer
Administrative
Small group ambassador
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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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
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.
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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
Name
This field is for validation purposes and should be left unchanged.
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