Al Amal Center for Human Rights and Justice

Competent Authority *

Ombudsman Office

National Institution for Human Rights

Local Human Rights Societies

Special Investigation Unit

Choose the entity or entities responsible for handling the complaint

Applicant Information ( the detainee / convicted )

Name *

Personal Number *

Applicant on behalf of (the detainee / convicted)

Name

Personal Number

Contact Information

Relationship

Specify the relationship between the proxy and the complainant (if applicable)

Physical or Psychological Mistreatment

Date of Mistreatment

Place of Mistreatment

Are there visible injuries?

Yes

No

Was a statement recorded?

Yes

No

Was the person seen by a doctor?

Yes

No

Health Care

What diseases does the person suffer from?

Mention any chronic diseases or special health conditions

Was he seen by the center's doctor?

Yes

No

Was he seen by a suitable specialist?

Yes

No

Were medications provided?

Yes

No

What is the current health status?

Temporary Release

For cases of death or marriage

Name

Personal Number

Relationship

Have you submitted a request to the execution judge?

Yes

No

Acknowledgment

I, the undersigned, hereby grant Stichting Al Amal for Human Rights and Justice full authority to represent me and speak on my behalf regarding my case/my family's case before: - Local institutions within the Kingdom of Bahrain. - International human rights organizations and bodies. - Any other relevant parties seeking to address or support my case. This authority includes: submitting complaints, correspondence, or statements, and following up on my legal and administrative case, with the center's commitment to use these powers exclusively within the human rights and humanitarian framework.

I agree to the acknowledgment

I do not agree to the acknowledgment

Full Name * Signature *

Please sign within the area above