Incident Details

What happened?

Other

I believe I was discriminated against because of my actual or perceived:

Date of Incident

Incident Description

What remedy/solution are you seeking?

This was something that...

OPTIONAL: Have you contacted any law enforcement agency regarding this matter?

OPTIONAL: Which agency?

Please be advised that ADL is neither a legal services agency nor a law enforcement agency. All potential criminal incidents should also be reported to local, state, or federal authorities, as appropriate. If you are fearful of reporting to police for any reason, please consider referring to this list of community support agencies/organizations.

Photo, video, or other file from incident:

Your Contact Info

First Name

Last Name

Phone Number (needed for a quick response)

Postal Code of Residence

Optional: I agree that for purposes of investigation, ADL and/or BBYO may use my name when making inquiries, including inquiries directly to the person or entity who allegedly committed the act(s).

BBYO Affiliation

Name of BBYO chapter you are connected with: (If none, please list N/A)

City of the chapter:

State of the chapter:

Your Role:

What is your official role in the chapter?

I agree that BBYO and/or ADL may contact the chapter I am connected with about this incident.

PLEASE REVIEW AND ACKNOWLEDGE ADL'S AND BBYO'S TERMS AND CONDITIONS

I agree to ADL’s and BBYO's terms and conditions, as articulated here.

PLEASE CHECK THE BOX THAT BEST DESCRIBES YOU:

I am 18 years of age or older (or an emancipated minor). I am under the age of 18. I understand that, in most circumstances, ADL and/or BBYO will not be able to take action on my behalf unless a parent or guardian is involved.

User Geolocation

Address & Map

Street Address

City/State

Zip / Postal Code

Country

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