Report Breastfeeding Discrimination

This form will collect the information we need to determine how best to
support a mother who has experienced discrimination due to
breastfeeding.

Your Name: *

Your Address:

Your Phone Number:

Your Email: *

Location of Incident: *

e.g. Anywhere Town Library, Here and Now Hot Dogs, ABZ Preschool

Name of Employee:

Name of person who instigated the incident

Address of location:

Phone Number of Location:

Date of Incident: *

Were there any witnesses?:

yes

Witness Name(s):

Witness Address(es):

Witness Phone Number(s):

Witness Email(s):

Detailed Description of Incident:

Other pertinent information:

e.g. Manager's name, Employees names, etc.

Legal Disclaimer

(required)
By checking here, I acknowledge I have read the following legal disclaimer.

FirstRight does not provide legal advice nor does it represent that it is or any of its employees or members are legal experts or qualified legal counsel. If you are seeking legal advice, please contact your local bar association, law society, phone book, or online directory to find, or obtain a referral to a competent professional. With respect to the information contained on this site or contained in any communication received from any employee or member of FirstRight, neither FirstRight nor any of its employees or members assumes any legal liability or responsibility for the accuracy, completeness or usefulness of its content.

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Report Breastfeeding Discrimination