Events

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 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:

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 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

Phone

This field is for validation purposes and should be left unchanged.

VOLUNTEER SURVEY

ATTORNEY INQUIRY

SECTION A

SECTION B

Section C

VACCINE INJURY

SECTION A

SECTION B

Section C

SECTION D

EMPLOYER MANDATE

SECTION A

SECTION B

School Mandate

SECTION A

SECTION B