Roxbury Park Community Center

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

Name

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

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