Students’ Civil Rights Project Intake Form

STUDENT'S NAME *

If you are not the student: YOUR NAME AND RELATIONSHIP TO STUDENT *

EMAIL *

PHONE *

ADDRESS *

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Your Pronouns

Examples of common pronouns are 'she/her/hers,' 'he/him/his,' and 'they/them/theirs.' If you’re comfortable, please share your pronouns:

TYPE OF INCIDENT *

(Please select all that apply)

School discipline
Denial of access to school programs/facilities
Denial of accomodations
Harassment/bullying
Sexual assault/rape
Intimate partner violence/dating violence
Retaliation
Other (Please Explain)

Describe "Other" incident

WHY DO YOU THINK YOU WERE TARGETED OR TREATED DIFFERENTLY? *

(Please select all that apply)

Describe the "Other" reason you were targeted

WHAT SCHOOL WERE YOU ATTENDING WHEN THE EVENTS OCCURRED? IN WHAT CITY/STATE? *

If different from above: WHAT SCHOOL DO YOU CURRENTLY ATTEND? IN WHAT CITY/STATE?

Tell us more about what happened.

PLEASE DESCRIBE WHAT HAPPENED. Please include when and where the events occurred, the names of the people involved, and any school employees who know about the events. *

DID YOU REPORT THE EVENTS TO ANY OUTSIDE AGENCIES? Examples include the U.S. Department of Education.

Yes
No

TIME SENSITIVE?

Please indicate if you have any upcoming meetings or events related to the incidents that you would like us to be aware of. (Such as, “Disciplinary hearing scheduled for next Monday, May 20.”)

Yes
No

If yes, please describe

PLEASE FEEL FREE TO SEND US ANY DOCUMENTATION THAT SUPPORTS YOUR CASE.

Drop files here or

Accepted file types: pdf, docx, doc, csv, xls, xlxs, jpg, gif, png, Max. file size: 15 MB.

Next Steps

You should receive an e-mail confirming receipt of your online request for assistance the same day that it’s submitted.
Generally, your request for assistance will be reviewed by Public Justice within two weeks of receipt (sooner, if time sensitive).
You may receive a follow-up phone call from a legal assistant, law clerk, or attorney to obtain additional information.

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