This scholarship is open to Polk County public high school graduating seniors who are interested in pursuing a career in the Emergency Services or Health Related Fields. This includes those continuing their education in the Criminal Justice, Law Enforcement, Paramedic, Firefighting or
Health Related Fields. Please submit your completed application and required documentation to your counselor by Friday, March 4 th , 2015.
Name:
Address:
Phone Number:
Student ID#:
ID # will be assigned by the scholarship committee.
Email:
Parent/Guardian Names:
Enclosures:
 Complete application
 Transcript
 List of Senior Year Classes
 Letter of Recommendation (not from a family member)
I certify that all information on this application is correct:
___________________________________
Student Signature
___________________________________
Parent/Guardian Signature
_____________________________
Date
_____________________________
Date

Student ID#:_______________
Section 1: Student Information
Plans for 2015-2016:
Intended Major:
School:
School:
(please complete if more than one)
Date Applied:
Date Accepted:
Date Applied:
Date Accepted:
Other Information:
List any hobbies or special interests:
References:
Please list three people that know you well, but you are not related to.
(Please do not list the individual that has written the letter of recommendation for you.)
Name
Address
Phone Number and Email if available
How you know this individual:
How long you have known this individual:
Do you have a family member that is employed in Law Enforcement? If yes, who and where?
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Section 2: Activities and Involvement
School Related Activities
: Please list any activities you have been involved in within the school setting.
Activities should include sports, music, art, forensics, clubs and any other in-school activities. Be sure to include any leadership roles you have held and any special recognition or accomplishments you received.
Please attach an additional page if needed.
Activity Years participated Recognition/Accomplishments
Non-School Related Activities:
Please list any activities, organizations, clubs or volunteer projects you have participated in during your high school years. Please be sure to include any leadership roles you have held and any special recognition or accomplishments you received. Please attach an additional page if needed.
Activity Years participated Recognition/Accomplishments

Student ID#:_______________
Section 3: Work Experience
Work Experience:
Please list all work experience you have had in your high school career. Include all part-time jobs you have held including babysitting, lawn clean-up, snow removal, lifeguarding, etc.
Job Title Job Description Years Employed Recognition/Accomplishments
Section 4: Essay/Narrative Response
Please answer the following three essay questions.
Use the following format:
• 12 point font, double spaced
• 1 inch margins
• List the question at the top of the page in bold and then respond.
• Each question should have a separate page.
• 200 words minimum for each question.
• Do not use your name or indicate your gender in the essay questions.
What are your goals for the future directly related to Emergency Services or Health Related Fields?
Describe your career objectives and how you hope to achieve them?
Describe a personal challenge or obstacle which you had to overcome and how you overcame it.
Describe someone who has had a significant impact on your life and why/how. During your high school career, who has influenced you the most, and why?
Section 5: Other Pertinent Information
Please provide any information not covered elsewhere in this application that you feel is essential for the readers to know. You may wish to include additional information regarding special circumstances or your family’s financial need situation.
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