Name
*
First Name
Last Name
How long have you lived at your current address?
*
Approximate Distance from Landfill
*
Community Residing in
*
Val Verde
Castaic
Canyon Country
Hasley Hills
Hasley Canyon
Hillcrest
Live Oak
North Bluffs
Piru
Sagus
Williams Ranch
Santa Clarita
Valencia
OTHER
If you have lived at your current address for less than 10 years, please provide your previous addresses going back to 2014:
Address, approximate dates, distance to landfill (approx.)
Date of Birth
*
MM
DD
YYYY
Health Symptoms (Check all that apply)
*
Other Medical Concerns (not listed)
Have you sought medical attention for any of the above-mentioned symptoms?
*
If you answered ‘YES’, did your medical provider believe that your above-mentioned symptoms could be environmentally caused?
Do you feel that your symptoms are:
*
Do you have a family history of any of the above-mentioned symptoms?
*
If you answered ‘YES’ above, please list your family's history;
Do you (personally) believe the Landfill has caused the above-mentioned symptoms?
*
Other Concerns (Check all that apply)
*
Other Concerns (not listed)
Do you spend a lot of time outdoors?
*
Do you work from home or nearby your residence?
*
How did you hear about this case?
*
Google Search
Press - LA Times, Signal, etc.
Neighbor
Nextdoor
Facebook
Instagram
Reddit
Co-Worker
Neighbor
Family/Friend
Flyer or Marketing
OTHER
