Peace Officer Application for Assistance

Peace Officer Application for Assistance

The form below is for Peace Officers, Corrections Officers, Fire Department Personnel, and EMT’s. Please fill out the below information if seeking assistance.  One of our Warrior Board members will be contacting you shortly.

Keep in mind, be as specific and detailed as possible.

We have helped not only using our own programs, but programs across the United States.  The more we know, the better we can get you connected to the right resources.

**Disclaimer:  Our Heroes’ Dreams does not share this information with 3rd parties or those outside of Our Heroes’ Dreams. The information obtained is only used to get you the help you need.  Our Heroes Dreams fully understands the need for confidentiality in these matters.

First Name

Last Name

Middle Initial

Gender
malefemale

DOB

Marital Status

Number of Children

Names and Ages of Family Members - Please List

Current Occupation

Street Address

City

State

Zip Code

Phone

Email

Department of Service

Rank

Any Specialties

Are You Still Active?
yesno

Our Heroes Dreams adheres to confidentiality in regards to the following questions. Any information you provide will not be disclosed to other agencies. Please check if understood
YesNo

Was/Were Your Injury(ies) a Result of
Work relatedAccidentIllness

Date of Injury

Is Your Injury
PermanentTemporary

Can You Provide Proof of Your Injury if Needed?
yesno

Circumstances Surrounding Your Injury(ies)

Types of Injury(ies) - Please be Specific

Medications Currently Taking: Prescribed and Non-Prescribed

Any Addictions or Allergies?

Legal Convictions (felonies or misdemeanors) or Issues? Please be Specific

Tell Us About Yourself

Interests or Hobbies - Please List

Other Information You Feel May Be Important

In What Areas Are You Looking for Help?

How Did You Hear About OHD?

If inquiring about financial assistance, Our Heroes Dreams does not release funds directly to the individual but to corporations, utility companies, mortgage holders, etc. You may be asked for billing account information as well as bank statements to determine eligibility or the need for budgetary counseling