DC Families for Safe Streets - Membership Form
Have you lost a loved one in a crash? Have you been injured or care for someone who was? No one should have to endure the physical, emotional and spiritual trauma of traffic violence alone.
DC Families for Safe Streets is comprised of individuals who have been injured or lost loved ones in traffic crashes and confronts the epidemic of traffic violence through advocacy and support. One of us will reach out upon your submission of this form.
1. General information
Preferred way(s) of contact
Phone (call and/or text)
Languages spoken (if fluent, please specify)
2. Crash information
I was injured
A loved one was injured / I am a caregiver
A loved one was killed
Name and relation of loved one injured or killed. If self, indicate self.
Birthday of loved one killed?
Type of crash
Pedestrian / Vehicle
Cyclist / Vehicle
Pedestrian / Cyclist
Vehicle / Vehicle
Hit and run
Are there or have there been any criminal charges in the case?
3. Other information
How did you hear about DC Families for Safe Streets?
If referred by a person, please provide name and affiliation.
We look forward to connecting with you further. Please let us know which of the following are of interest to you:
Please feel free to share any additional thoughts.
Send me a copy of my responses.
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