Dublin Police and Fire Scholarship

Download Dublin Police and Fire Scholarship Application

    Applicant Information

    First Name

    Middle Name

    Last Name

    Email Address

    Birth date

    Ethnicity/Race

    Current Grade level

    Gender

    Date

    Home Phone number

    Phone Number of applicant

    Street Address

    Street Address line 2

    City

    State

    Zip code

    Name of High School

    Phone Number of High School

    What is your High School GPA?

    Name of college (if known)

    Student Identification Number (if in college)

    Has the applicant been previously awarded a Dublin Police and Firefighter Scholarship?

    YesNo

    Does the applicant have a physical or mental impairment?

    YesNo

    If so, please specify.

    What extracurricular activities is the applicant involved in? (provide brief description)

    First Responder/Employee Parent Information

    Full name of First Responder/Employee Parent

    Employee of (list township/department below)

    Is First Responder/Employee parent currently serving?

    YesNo

    If answered no to the above question, specify below

    RetiredDeceased

    Full name of parent/guardian of applicant

    Date of Birth of Parent/Guardian

    Phone Number of Parent/Guardian

    Email Address of Parent/Guardian

    Annual Household Income

    Number of Household Members

    Essay Questions

    Essay Question #1 : If you are a child of a current or retired First Responder: How does your parent being a First Responder affect your life, values, and/or future? (500 word limit)

    Essay Question #2 : If you are not a child of a First Responder: What does it mean to you to be educated? How will higher education help you achieve your future goals? (500 word limit)

    Terms and Conditions

    The undersigned applicant and First Responder/employee of Dublin Police Department, Shawnee Hills Police Department,
    Washington Township Fire & EMS, or Concord Township Fire & EMS represent and warrant that the information provided in this scholarship application is complete, true, and correct in every aspect. I acknowledge and agree that any failure to provide such complete, true, and correct information is grounds for immediate revocation of any scholarship awarded. This application must be received by 11:59pm on April 23rd, 2021.

    Date

    Applicant Signature

    Parent/Guardian Signature

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