Services are subject to available funds at the time of the request.

Services are available to First Responders who have been wounded, injured or critically ill. 

We will need proof of employment or volunteer status on letterhead from an employer/volunteer agency or a legible copy of your position identification card.

First Responders (Police Officer, Fire Fighter, EMS, 911 Dispatcher)

Today's Date
Full Name (First, Middle, Last)
Street Address (Include Apt #)
City
State
Zip Code
Date of Birth
Last 4 of your SS Number
Phone Number
Your Email
Please specify the group of First Responders that you are classified as: (Operation First Response considers the following as a First Responder: Police Officer, Firefighter, EMS, 911 Dispatcher)
Employer/Volunteer Agency
Employer/Volunteer Agency Representative's Name and Contact Number
Employer/Volunteer Agency Representative's Professional Email
What Illness or injury caused you to be in need of financial assistance? (Be prepared to have written proof of your situation)
Break out each need and its amount (example: rent $, utility $, groceries $ etc... NOT JUST A TOTAL)
Would you be interested in taking an online Cisco Certified Network Associate Course for no cost to you?
Would you be interested in taking an online CompTIA Security+ Cyber Security Course for no cost to you?
The requestor agrees that the name appearing in the signature block below is the true and legal name of the requestor and serves as an electronic "signature" to this request form. (This must be the First Responder’s signature)
*VERY IMPORTANT*
Please Note
Please Understand The Following
Submit