The Police Survivors

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Membership Application
All Information In Regards To Counseling Is Strictly
Confidential And Is For Internal Use Only

This organization was created to assist Illinois Law Enforcement Officers who have been seriously injured in the line of duty through a traumatic event.  This organizations sole purpose is to assist with issues regarding the recovery of every injured Officer.  Financial assistance may only be applied for within one (1) year of the date of injury, membership may be applied for anytime.

Types of Membership:

Executive Members are Police Officers who have been seriously and traumatically injured in the line of duty. Only these members can serve of the Board.

Regular Members are Police Officers who have arrest powers in the State of Illinois who share in the ideas and philosophy of this organization.

Honorary Members are individuals who have demonstrated a knowledge of, and sympathy for the ideals and aspirations of this organization.

Associate Members are individuals, or civic, business, labor, or government organizations that support, financially or otherwise, the purpose and mission of this organization.

Please understand that we provide financial assistance and that we are not a loan company.  There is no expectation that this money be repaid.  Financial assistance will only be granted to officers who have suffered a traumatic injury within one (1) year of this submission of this application.


By accepting any financial assistance you give us the right to use your story in our publication(s), website, etc., pertaining to the Police Survivors.  You understand that our organization is a volunteer organization and we encourage you to take part.  Any financial assistance beyond the initial grant is subject to review.


Need an application?  Click on the Word document icon to the right, print the form, and either mail it or fax it to us.  To submit your application electronically, see below.
Document
Membership Application
Online Application
First Name
Middle Name
Last Name
Spouse's Name
Street Address
City
State
Zip Code
E-mail Address
Home Telephone() -
Work Telephone() -
Mobile Telephone() -
Police Department
Rank/Title
Day Off Group
Watch
Current Duty Status
Would you be willing to participate in Home Visitations? (Y/N)
Would you be willing to participate in Hospital Visitations? (Y/N)
Would you be willing to participate in Scene Visittions? (Y/N)
Would you be willing to participate in Academy Visitations? (Y/N)
Would you be willing to participate in Public Speaking Engagements? (Y/N)
Which level of membership are you applying for?
Please describe in detail your incident and the injuries you sustained:

If you'd like to submit additional information, or include the description of your incident in an attachment, please feel free to email it to webmaster@thepolicesurvivors.com.
Disclaimer: The Police Survivors is an Illinois not-for-profit corporation.  Opinions posted on www.thepolicesurvivors.com are those of the individual posters and do not necessarily represent the opinion of The Police Survivors or its board.  All materials posted herein are protected by copyright law and the exemption for fair use of copyrighted works.