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Startseite
About Us
Opt-in
Volunteer
Donate
Donate to CA Chapter
$10 in ’23 Campaign
Donate Recurring
Legal Tools
Legislation
CA Bills
CA Legislative Resources
Events
News
Media
Autism
Ressourcen
Vaccine Resources
Books to Read
College Mandates
Employment Resources
Advocacy
Latino Resources
Instagram
Twitter
YouTube
Rumble
Suche
Employment Resources
Find an employer aligned with medical freedom values at
Red Balloon
.
×
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
Amerikanisch-Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgien
Guam
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
Nördliche Marianen
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Jungferninseln
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
Amerikanisch-Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgien
Guam
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
Nördliche Marianen
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Jungferninseln
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
Amerikanisch-Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgien
Guam
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
Nördliche Marianen
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Jungferninseln
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
E-Mail
This field is for validation purposes and should be left unchanged.
Δ
×
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
Amerikanisch-Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgien
Guam
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
Nördliche Marianen
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Jungferninseln
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
Amerikanisch-Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgien
Guam
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
Nördliche Marianen
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Jungferninseln
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
PHONE
EMAIL
COUNTY
Telefon
This field is for validation purposes and should be left unchanged.
Δ
×
VOLUNTEER SURVEY
First and Last Name
*
First
Last
Email
*
Phone
*
The phone number provided is my:
Mobil
Startseite
Work
Address
Street Address
Address Line 2
City
Alabama
Alaska
Amerikanisch-Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgien
Guam
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
Nördliche Marianen
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Jungferninseln
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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.
Δ
×
Legislation
First Name
(Required)
First
Email Address
(Required)
Δ
×
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
Alabama
Alaska
Amerikanisch-Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgien
Guam
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
Nördliche Marianen
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Jungferninseln
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
Amerikanisch-Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgien
Guam
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
Nördliche Marianen
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Jungferninseln
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
SUPERINTENDENT PHONE
SUPERINTENDENT EMAIL
PRINCIPAL NAME
First
Last
SCHOOL ADDRESS
Street Address
Address Line 2
City
Alabama
Alaska
Amerikanisch-Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgien
Guam
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
Nördliche Marianen
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Jungferninseln
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
SCHOOL PHONE
SCHOOL EMAIL
COUNTY
E-Mail
This field is for validation purposes and should be left unchanged.
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