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Children’s Health Defense^® is a 501(c)(3) non-profit organization. Our mission is ending childhood health epidemics by eliminating toxic exposure. We will restore and protect the health of children by eliminating environmental exposures, holding responsible parties accountable, and establishing safeguards to prevent future harm of children's health. Protecting Children. Exposing Harms. Seeking Justice.

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Name*

First Last

Email*

Phone

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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 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 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 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
Name
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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 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 State ZIP Code
PHONE
EMAIL
COUNTY
Name
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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 State ZIP Code
County of residence
What part of California do you live in?
- Northern CA
- Central CA
- Southern CA
What is your profession and job 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
Approximate number of hours available to contribute to CHD-CA Chapter? Please list days and hours.
Please note that we are looking for volunteers that can contribute a minimum of 10 hours per week.
Provide any other information that maybe helpful, such as: business website, social media links, client reviews, awards, etc.
List two personal references known for 1 year or more, who know your beliefs. Include name, phone, email, and relationship.

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Legislation

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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
CONTACT PHONE*
PHONE
CONTACT 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
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 State ZIP Code
SUPERINTENDENT PHONE
SUPERINTENDENT EMAIL
PRINCIPAL NAME
First Last
SCHOOL ADDRESS
Street Address Address Line 2 City State ZIP Code
SCHOOL PHONE
SCHOOL EMAIL
COUNTY
Email
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