Fair Warning Notice Form

Name*

First

Middle

Last

Your spouse (if applicable)

First

Last

Please upload a scan of your Driver’s License or other government ID. If current address is different than what is indicated thereon, please complete current address form below. *

Address

Street Address City State / Province / Region Postal / Zip Code

Primary newspaper publication where you live:*

County:*

County seat:*

COMMUNICATIONS: If you don’t yet have a protonmail (encrypted for privacy) email address, please consider getting one. ‘Free’ is an option: https://protonmail.com/ Please provide your email below; make sure ctwh@pm.me is in your address book. (We will communicate largely through email, but just in case.)

Phone*

Do you have children to protect under this SPECIAL NOTICE? (If so, also complete section below named "Your children")

Yes

No

Help us help you by identifying your ethnicity.

Check here if you are anything other than ‘white’ or ‘Caucasian.’ Special wording is required to protect your rights.

The notice primarily addresses your right to not be vaccinated against your will. If you want your right to not wear a mask to be included, check this box. Then, plan to be single-minded about this issue; do not wear a mask ever unless in specific applicable environments (If you are seen wearing a mask in some venues but not others, you may prejudice your rights regarding not being required to wear a mask. If you are a nurse or healthcare worker or hazmat or in a field that properly requires a mask, please let us know. The wording will include that you will honor mask protocols in this environment but will not be subject to wearing a mask in other non-applicable environments.)

Yes

No

County Sheriff*

Street Address City State / Province / Region Postal / Zip Code

Employer

Street Address City State / Province / Region Postal / Zip Code

School

Street Address City State / Province / Region Postal / Zip Code

Hospital

Street Address City State / Province / Region Postal / Zip Code

Nursing Home

Street Address City State / Province / Region Postal / Zip Code

Addt'l Entity 1

Street Address City State / Province / Region Postal / Zip Code

Addt'l Entity 2

Street Address City State / Province / Region Postal / Zip Code

Addt'l Entity 3

Street Address City State / Province / Region Postal / Zip Code

Your children:

Child number 1

First

Last

Age

Child number 2

First

Last

Age

Child number 3

First

Last

Age

Child number 4

First

Last

Age

(Only list those for whom a notice will be filed.)

(If you have more than 4 children to protect or if any live at a different location, please provide that information below.)

Comments, Questions or Additional Information

Word Verification