Private Residence

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)

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PARENT
TEACHER
SCIENTIST
ADMINISTRATOR
HEALTH PRACTITIONER
GRANDPARENT
OTHER

WHAT IS YOUR CONCERN (CHECK ALL THAT APPLY)

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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

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):

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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

Comments

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Location

Next Event

Upcoming Events

VACCINE INJURY

SECTION A

SECTION B

Section C

SECTION D

EMPLOYER MANDATE

SECTION A

SECTION B

VOLUNTEER SURVEY

School Mandate

SECTION A

SECTION B