APPLICATION FOR CARLOS LILLO MEMORIAL SCHOLARSHIP

Please check off/complete as it applies to you

EMERGENCY MEDICAL TECHNICIAN – BASIC PROGRAM --YEAR ______

HEALTH-RELATED FIELD/MAJOR: ______-- YEAR ______

(Please Print or Type information on form)

Applicant’s Full Name:

Address:

Telephone #: Home: ( ) Cell: ( )

Please indicate the best time to reach you:

Emails: ______

Grade or Grade Point Average/Scale: ______Class Rank ______Class Size _____

Date of Birth: Social Security #:

Place of Employment (If applicable):

Address: Position:

Parents/Guardians with whom you live:

Father’s Name: Mother’s Name:

Parent (s) Place of Employment Position/Title

Father:

Mother:

Household Total Annual Income $

Total # of persons in your family dependent on this income:

Have you applied to a college or trade school?

Were you accepted?

Name of College or trade school:

What is your major or trade desired?

Have you applied for other scholarships, financial aid, loans, or other assistance? List below

Have you received confirmation of being awarded any scholarships, financial aid, loans, or other assistance? (Be specific)

If awarded the EMT-Basic scholarship, will you attend college or trade school after graduating from EMT school? (Explain)

Do you see yourself pursuing a career in emergency medical services/health related field? (Explain in detail)

List groups, clubs, school, church and/or community activities, volunteer work, etc. in which you have been involved in during high school: (Attach separate sheet if needed)

List any honors, awards, or certificates received from these or any other organizations: (Attach

Separate sheet if needed)

List at least three (3) references – one of each of those listed under the requirements section.

Written recommendations must be attached.

Name: Relationship To Applicant: Telephone:

(1)

(2)

(3)

Attach an essay, official grade transcript, proof of acceptance to program/college, and written recommendations, according to instructions.

I hereby acknowledge and confirm that I read and understand the information on this application and that all information submitted as part of this scholarship award is accurate and complete to the best of my knowledge. (Please print and sign name and date below/)

Applicant Name (print): ______

Applicant Signature:

Date:

Revised EMT Program form rev. 5/7/09; revised 11/8/09

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