AFLDS Adventist Constituent Form

AFLDS Adventist Constituent Form

AFLDS is looking for Adventist employees or workers whose job wants to force them to take the Covid-19 vaccine. Please fill out this form (there are no “right” answers but please be accurate!!) if you are even THINKING about legal action! Even if you have chosen to be vaccinated but you don’t want to live in a country where your employer can do such things, please fill out the form. If your information matches our criteria, our legal team will get in touch with you. You can share this link with other Adventist workers: https://americasfrontlinedoctors.org/adventist
Name*

First NameLast Name
Email*
example@example.com
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Home Address*
If you have a “home” address that is in-state, please use that address.
City*
State*
ZIP Code*
County*
Select State of your Job*
What is the address of your place of employment?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Did your employer post a list of workers who did not have the vaccine?*

YesNo
If your employer posted a list of workers who did not have the vaccine, how long was the list publicly available?*
What date was the list posted from and to?*
Do you have a photo of the posting?*

YesNo
Where in the hospital was it posted, name all locations.*
Do you know of plan the hospital has to continue posting?*

YesNo
Who is responsible for ordering this posting/directive?
Do you have a employee handbook in your possession? If so, please email to hgibson@gibsonhealth-law.com and jessica@@gibsonhealth-law.com*

YesNo
Have you already submitted an exemption request to your job?*

YesNoOther
Have you ever had Covid-19?*

YesNo
Evidence of prior Covid-19?*

PCR TestAntibody TestSymptomsN/A
Have you or a family member ever had a bad reaction to a vaccine in the past?

YesNo
Please explain:
Do you have a health issue which you feel puts you at risk for taking the Covid vaccine?

YesNo
Please explain:
I’ve taken the Covid Vaccine and am experiencing adverse reactions or events?

YesNo
Please explain:
Summarize your Concerns/Free Narrative
You understand that you are submitting personal information related to your health. Your data will NEVER be shared, sold or rented.*

I Understand
Should be Empty: