• The Jack Gargalino Memorial Foundation First Responder Application for Benefits

  • Founded in 2022, the Jack Gargalino Memorial Foundation is a 501(c)(3) charity that provides direct financial support to first responders—military, police officers, firefighters, and EMTs—who are facing unexpected hardship due to injury, illness, or other life-altering events.

    Qualifications: 

    • Legal resident of the United States
    • A current or former first responder or the immediate family member (spouse, child or dependent) of a first responder
    • Demonstrate a financial hardship due to:
      • A line-of-duty injury
      • A diagnosed medical condition (physical or mental)
      • A critical life event (e.g. natural disaster, loss of home, funeral costs, etc.)
    • Applicants who receive assistance may be invited, when appropriate, to provide a brief voluntary update or attend a Foundation event so the Foundation can share the impact of donor support. Participation is optional and will not affect eligibility for assistance. The Foundation will not publicly share personal medical, financial, or family details without the recipient’s written permission.

    *Persons may reapply for succeeding years

  • Officer Information

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  • Date of Birth
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  • Officer Employment

  • Employment Date
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  • Spouse Information

    If Applicable
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  • Date of Marriage
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  • Dependent Information

    If Applicable

  • Injury Information

  • Date of Injury
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  • Have you applied for benefits

  • Receiving Worker's Compensation benefits?

  • Do you have disability insurance?

  • Financial Information

  • Areas of Hardship

  • Rows

  • Recipient Updates, Event Participation, and Privacy

    If selected to receive assistance from the Jack Gargalino Memorial Foundation, I understand that I may be invited to provide a brief update or attend a Foundation event so the Foundation can share the impact of donor support. I understand that any participation is voluntary and will not affect my eligibility for assistance.

    I also understand that the Foundation may share general information about the impact of its assistance with donors and supporters through Foundation communications, including the Foundation website, social media, printed materials, and future fundraising events. The Foundation will not publicly share personal medical details, financial details, sensitive family circumstances, or other private information without my written permission.

    By accepting assistance, I agree that the Foundation may share my name, general first responder affiliation, assistance year, and any photo, statement, or update I choose to submit for Foundation-related purposes, unless otherwise requested in writing.

    Applicant Affirmation

    I affirm that all statements I have indicated herein are true and correct to the best of my knowledge. I understand that any misrepresentation I have made may result in the invalidation of my application and may bar me from re-applying for assistance from the Jack Gargalino Memorial Foundation.

  • Date Signed by Applicant
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