Application Process:  Please fill out this form in its entirety and read carefully.  Any lines left blank will eliminate this request from consideration.  If the question does not apply to you, N/A is the appropriate answer.  The application will be reviewed and voted upon by our full Board.  Approval requires a 2/3 vote of the Board members.   You will be notified of the decision in writing following the vote.

Eligibility Rules:   The Firefighter or Law Enforcement Officer must live in Gibson, Posey, Vanderburgh, or Warrick County, Indiana or Henderson County, Kentucky. There must be an immediate and pressing financial need on the family that cannot be met through other means, resulting from a natural disaster or fire.       

Criteria for Selection:  911 Gives Hope, Inc will base its decisions on availability of funds, priorities assigned to other purposes as stated in its by-laws and evaluation of the application. 

Maximum Grant:  The maximum grant per application is $5,000.00. In specific cases where a special event fundraiser is arranged on your behalf, the maximum grant available will be the amount raised, limited to the amount of your need.  If the amount raised is in excess of your need, the balance will be applied to our general fund to be used to help others.  You may only apply once in a six (6) month period.

Applicant's Full Name: *

Applicant's Address, Phone, email: *

Name, Age, Address and contact information of Firefighter/Law Enforcement Officer: *

Explain the circumstances of the Natural Disaster or Fire affecting the Officer/Firefighter: *

Is the Officer/Firefighter covered by Insurance?: *

No

Yes

If yes, explain the coverage details. If no, please explain the reasons: *

Tell us about the Officer or Firefighter affected by the disaster or fire: *

Briefly state why the Firefighter or Officer needs assistance from 911 Gives Hope: *

Is the Officer/Firefighter willing to share applicable financial information with our Board: *

No

Yes

Has the Officer/Firefighter previously received funding from 911 Gives Hope?: *

No

Yes

If yes, when and provide an update as to how the funds were used.:

Have you or the Firefighter/Officer requested funding for this need from any other organizations?: *

No

Yes

Status of that Request:

Granted

Denied

Pending

If Granted what was provided?:

In what other ways have you tried to raise funds to recover from this event?: *

Has anyone in your family attended, volunteered, or participated in any 911 Gives Hope events? For example, Guns & Hoses, 5K Hope Run, etc.? If so, please describe. : *

How did you hear about 911 Gives Hope? : *

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