What We Fund

Scholarship Request Form

Scholarship

Which scholarship are you applying for?

Personal Information

First Name

Middle Initial

Last Name

Address

City/State/Zip Code

County of Residence

Telephone

Email Address

Date of Birth

Place of Birth

College/University

This application is for the academic year beginning:

Name of college or university to be attended:

Financial Aid Address

Program of Study

Proposed occupation or profession

Where did you previously attend college

When

High School

High School attended

Year Graduated

Most Recent Transcript

Work Activities

Are you currently working?

# of hours per week

Do you plan to continue working during college?

# of hours per week

Child of

Are you a Child or Stepchild of Volunteer Firefighter or EMT?

Name of Parent

Extra-Curricular

Extra-curricular or community activities including employment experience

Organization/Club/Offices Held

Achievements/Recognition

Essay

A 250 word essay stating your reasons for choosing a healthcare profession and how you anticipate that this education opportunity will enable you to enhance patient care at Sidney Health Center.

Financial Need Statement