Community Support Form

The purpose of this form is to collect data on incidents of harassment and discrimination in the City of La Verne and provide members of the community access to restorative justice by providing a platform and a space for dialogue. We use the data to create programs, resources, and connections that respond to the diverse needs of the La Verne community.

Name

First Name

Last Name

Phone

(###)

###

####

Preferred Form of Contact

Date of This Report

YYYY

Approximate Date of Incident

YYYY

Please explain the incident

Be as specific as possible, including approximate time and location, parties involved, what happened, and how it ended

Was the other party a

Desired outcome

To be heard

To inform CASI

Mediated discussion with the other party (if they are willing)

Assistance communicating your issue to city leadership

Referral to legal resources

Opportunity to participate in making the city better

Other, please specify in your summary

How did you hear about us?

Community Support Form

Info

City of La Verne’s Committee on Cultural Awareness and Social Inclusion