Scholarship Application
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Wilton Firefighters Association
Scholarship Program
9800 Dillard Road, Wilton, CA 95693
Date: *
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Applicant Name *
Mailing Address (Street, City, State, Zip) *
Phone number *
Email *
EMT Training
Date Completed EMT-B Course: *
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School Where Completed EMT-B: *
National Registry (EMT) Pass Date: *
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NREMT Number: *
List all EMT continuing education courses and other EMS training done after completing the EMT-B Course: *
Other Education
Date Graduated High School, or Date Passed GED Exam or Calif. High School Proficiency Exam: *
College Degree or Certificate, Date, Subject, and Name of College: *
College Degree or Certificate, Date, Subject, and Name of College: *
If you have already passed any of the prerequisite courses for paramedic school, state where you took each course, the course number, full course name, date of completion, and grade received:Please list any other EMS-relevant college classes you have completed, including where you took each course, the course number, full course name, date of completion, and grade received: *
Experience With Wilton Fire Protection District
Date Commenced WFPD Service: *
Approx. Total Hours Worked for WFPD: *
Approx. No. of Patient Contacts With WFPD: *
Approx. No. of Total Patient Contacts After Completing EMT-B: *
Non-WFPD Work Experience (Paid or Unpaid, Including Fire Academy and Military Service) In The Last 5 Years.
MOST RECENT Dates of Service: Position: Organization: Organization Mailing Address: City, State, ZIP: Dates of Service: Main duties, and EMS-relevant skills developed on the job: Supervisor: Supervisor's Phone No.: *
NEXT MOST RECENT Dates of Service: Position: Organization: Organization Mailing Address: City, State, ZIP: Dates of Service: Main duties, and EMS-relevant skills developed on the job: Supervisor: Supervisor's Phone No.: *
NEXT MOST RECENT Dates of Service: Position: Organization: Organization Mailing Address: City, State, ZIP: Dates of Service: Main duties, and EMS-relevant skills developed on the job: Supervisor: Supervisor's Phone No.: *
NEXT MOST RECENT Dates of Service: Position: Organization: Organization Mailing Address: City, State, ZIP: Dates of Service: Main duties, and EMS-relevant skills developed on the job: Supervisor: Supervisor's Phone No.:
Professional References Who Know You Well (One Currently or Formerly With WFPD, and One Outside WFPD) WFPD Reference: WFPD Reference Phone No. Nature of Your Professional Relationship: Non-WFPD Reference: Non-WFPD Reference Phone No. Nature of Your Professional Relationship: *
Paramedic Programs and Areas of Interest
If you have already applied to a paramedic program, are already accepted into a program, or are currently enrolled in a program, please state the paramedic school name, location, and all relevant details: *
If you have not yet applied to a paramedic program, please identify the program you are most interested in joining, and explain why: *
What is the one thing you are most interested in learning in paramedic school? *
What aspect of paramedic school are you most apprehensive about, and what steps have you taken to prepare for it? *
Notable EMS Experience
Please describe what you feel is the most interesting EMS call you have participated in, and including what you learned from it: *
Please describe the most stressful EMS call you have handled as the lead EMT or only EMT, including what you learned from it: *
Describe a time when you provided excellent customer service as a firefighter or EMT: *
Service to the Community
Please describe the extent of your participation in activities of the Wilton Firefighters Association, such as the Chili Cookoff & Classic Car Show, other fundraisers, and public service events (such as the Memorial Day service): *
Describe your volunteer participation in other community events, school events, charity events, and other service-oriented activities: *
Extracurricular Activities
Please describe your main interests, passions, and recreational activities other than firefighting and EMS: *
Why have you chosen your current career choice and how do you see yourself in this occupation twenty years from now? What will you have contributed to it? *
Service to the Community
Certification and Release Certification
Please state any additional information you feel may be helpful to us in considering your application. You may also use this space to supplement answers for which there was insufficient space above *
By typing my name in this electronically-submitted application, and by submitting this application, I: (1) certify each answer I provide here is complete and true to the best of my knowledge; (2) authorize the Wilton Firefighters Association to verify the information submitted here; (3) grant WFA permission to contact the persons listed as references or supervisors regarding my application for this scholarship; and (4) allow WFA to use my name and photograph for publicity purposes.
I agree to submit a proof of Enrollment *
Print Full Name: *
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