Contact Us: Discrimination in Public Facilities

The Blue Form

The Obesity Law and Advocacy Center

	Contact Form
	Discriminated Against
	Based on Size

PLEASE FILL OUT THIS FORM IF YOU BELIEVE YOU HAVE BEEN DISCRIMINATED AGAINST BASED ON YOUR SIZE IN ACCESSING A PUBLIC FACILITY (RESTAURANT, AIRLINES, HEALTH CARE FACILITY, ETC.)

(THIS FORM IS ENCRYPTED ON A SECURE SERVER FOR YOUR PRIVACY)

In order to assist us in evaluating whether we can help you, some basic information is required. Please take the time to fill out this form COMPLETELY and follow the instructions at the end. You will receive an email from us confirming our receipt of your information and a personal telephone call from the office to further discuss the matter once we've evaluated this material. Thank you for your cooperation.


Name
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone
FAX
E-mail


	How did you hear about us?



	Describe the public facility you were denied access to because of
	your size?




	If you were charged a "Premium" for a public service (for example,
	ambulance services) because of your size, please describe the
	incident and the amount of that charge?




WE NEED TO GET SOME INFORMATION ABOUT YOU IN ORDER TO EVALUATE THIS MATTER. WHILE IT MAY SEEM VERY PERSONAL IN NATURE, PLEASE UNDERSTAND THAT IT IS NECESSARY IN ORDER FOR US TO DETERMINE WHETHER WE CAN HELP YOU.


	Please identify and describe yourself:

Age
Gender			Male Female
Height
Weight


	Have you filed any formal charges or complaints because of this
	incident with either a state or federal agency?

		Yes
		No


	If yes, what is the status of that proceeding?




	Do you have an attorney representing you currently?

		Yes
		No


	If yes, please provide his/her name, address, and phone number:




	Can we contact this attorney?

		Yes
		No




Form may take a moment to process. Your patience is appreciated.

ObesityLaw.com






Obesity Law & Advocacy Center
1392 East Palomar Street
Suite 403-233
Chula Vista, CA 91913



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Mail Address: Obesity Law & Advocacy Center, 1392 East Palomar Street, Suite 403-233, Chula Vista, CA 91913

Telephone: 619.656.5251

FAX: 619.656.5254

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