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
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?
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
$0-$50k$51k-70k$71k-90k$91k-110k$111k-130k$131k-150k$151k - $170k$171k - $200k$200k - $250k$251k +
Number of Household Members
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)
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 February 20th, 2020.