Grievance Form
The Miracles Club is committed to offering equitable, trauma informed, culturally specific services to our community. If for any reason you have a complaint against Miracles or Miracles staff, please contact our HR department utilizing this grievance form. Feel free to leave contact information or remain anonymous, whichever feels right for you.
Date
*
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Month
-
Day
Year
Date
Name (optional)
First Name
Last Name
Email (optional)
example@example.com
Phone Number (optional)
-
Area Code
Phone Number
Home Address (optional)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Details of Event Leading to Grievance
Date and Time of Event
*
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Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Location of Event
*
Witnesses (if applicable)
Account of Event
*
Please provide a detailed description, including the names of all persons involved.
Attach additional documents if needed
Browse Files
Cancel
of
Would you like to be contacted regarding this event?
*
Yes
No
If yes, what is the best way to contact you? (Please make sure you have entered your contact information above.)
Phone call
Email
Submit
Received by:
First Name
Last Name
Signature
Should be Empty: