KENTUCKY EMERGENCY MEDICAL TECHNICIAN

INSTRUCTORS ASSOCIATION

SCHOLARSHIP APPLICATION

A. Complete all requirements of the Scholarship Application

2. Please type an essay of approximately 250 words on your role in and perspective of Emergency Medical Services and reasons why this scholarship should be awarded to you.

3. A minimum of one and no more than three recommendations must be submitted with the application.

4. School/community/work experience and awards/honors/special recognitions (use a separate sheet to answer.)

SS# _______________ Name ___________________ Sex* ______ Age* _________

First Last Maiden

Home Address ________________________________________________________

Street/Box Number City State Zip

County ________________ Home phone number ( ) ________________

Name of school/program ______________ Date of graduation _________________

Major/field of study __________________ Possible occupation choice __________

Applicant gross family income __________ Number of household members ______

Name of sponsoring KEMTIA member ____________________________________

Address _____________________________________________________________

Note: Information marked with an (*) is optional.

I HEREBY ATTEST to the accuracy of the information I have included in this application and give my permission for the use of my information in media releases or internal audits. I understand myfull application is to be reviewed by members of various selection committees. I understand that KEMTIA retains the right to adjust my individual scholarship awards to effectively utilize KEMTIA dollars.

SIGNATURE DATE