First Responder Eligibility Form

Please take a moment to fill out this First Responder specific questionnaire

First Name *

Last Name *

What First Responder Branch are you in? *

Law Enforcement

Fire/EMS

US Military

Other

Employment Status *

Years as a First Responder *

End Date of Employment (if applicable)

I incurred... *

A visible or invisible injury, illness, or wound.

Was not injured or do not remember when injuries occurred

Has a chronic injury/illness and does not have a specific date of injury.

Other

First Responder Eligibility Documentation

In order to confirm your eligibility for WRP services, we ask that you submit a document that proves your employment as a First Responder. Additional information or documentation may be needed to confirm eligibility.

First Responder Eligibility Documentation *

Upload Eligibility Documentation