Dublin Police and Fire Scholarship

Applicant Information

Email Address

Birth date

Ethnicity/Race

Home Phone number

Phone Number of applicant

Street Address

Street Address line 2

Name of High School

Phone Number of High School

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

What is your High School GPA?

Essay Questions (Only respond to essay question #2 if you are the child of a First Responder)

Essay Question #1 (choose one): Explain how an experience in your life has impacted who you are today. (750 word limit)

Essay Question #2: What are some hardships you face being the child of a First Responder? (750 word limit)

Terms and Conditions

The undersigned applicant and First Responder/employee of Dublin Police or Washington Township parent represent and warrant that the information provided in this scholarship application is complete, true, and correct in all material respects. I acknowledge and agree that any failure to provide such complete, true, and correct information is grounds for immediate revocation of any scholarship awarded as a result of the information provided in this application. All scholarship applications must be received by

Applicant Signature

Parent/Guardian Signature

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