ACTS OF KINDNESS REQUEST FORM
The Western New York Law Enforcement Helpline’s Acts of Kindness Initiative is to provide outreach and support to law enforcement officers and their families who have experienced hardship as a result of a critical incident, personal or job related death, injury, loss of income, or illness, and event causing significant emotional distress for law enforcement and/or immediate family. Acts of Kindness is intended to let law enforcement families know that they are thought of and cared about during difficult times.
     

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Date *
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/
DD
/
YYYY
Name of Person requesting Act of Kindness *
Person making request *
Required
Phone number of person making request *
Please check one of the following reasons for the request. *
Required
Please give details regarding the option checked above. *
Name of recipient *
The recipient is: *
If you selected family member please explain family members relationship to law enforcement. *
Are any members of the family veterans? If yes, please indicate how many?
Name of city where recipient resides. *
First name of significant other.
Does recipient have children living in the household? *
Required
Please list age and sex of each child living in household. *
Does the recipient have a pet? *
Required
Delivery Information *
Required
If you checked off delivery to be made by the helpline please provide recipient's phone number, address and place of employment.
If there is any other pertinent information you feel we need, please list here.
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