CaucasianBlack/African AmericanHispanic/LatinxAsian/pacific islanderNative AmericanOtherPrefer not to sayMore than one Ethnicity/Race
Current Grade level
graduate schoolvocational school12th1st year in college2nd year in college3rd year in college4th year of college
MaleFemaleOtherPrefer not to say
Home Phone number
Phone Number of applicant
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?
Does the applicant have a physical or mental impairment?
If so, please specify.
What extracurricular activities is the applicant involved in? (provide brief description)
Full name of First Responder/Employee Parent
Employee of (list township/department below)
Is First Responder/Employee parent currently serving?
If answered no to the above question, specify below
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 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)
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