Regional EMS Award for Outstanding Contribution to EMS by a Student Nomination Form

This competitive $1,000 scholarship will be awarded to a high school senior, or recent high school graduate or GED recipient who is 21 years of age or under, and is currently affiliated with an EMS agency, and has been affiliated for at least 90 days, and is currently enrolled or will be enrolled in an institution of higher learning or an accredited ALS training program in the coming year.

Select Award Category*

Award for Outstanding Contribution by a Student (Scholarship)

Select Regional EMS Council*

Applicant Name*

Applicant Address*

Applicant Email*

Applicant Home Phone

Applicant Cell Phone*

Applicant Agency Affiliation*

Applicant Certification Number*

Member Since*

GPA*

Current Cumulative

GPA Based on Point Scale

GED Score (if applicable)

Anticipated Higher Education/ALS Institution*

Anticipated Higher Education/ALS Institution Start Date*

Proposed Major/Area of Study*

Parent/Legal Guardian Name and Phone Number*

Items That Must Accompany This Application Form

1.) Proof of the applicant’s affiliation with a Virginia licensed EMS agency. Statement on agency letterhead can be included as part of one of the letters of recommendation. 2.) A copy of the applicant’s official high school or GED transcript (no minimum GPA or GED transcript is required, but will be considered in evaluations.) 3.) At least two letters of recommendation on appropriate letterhead attesting to the nominee’s academic and/or EMS performance, which is consistent with the highest standards. One of the two letters of recommendation must be from an agency officer attesting to the applicant’s level of activity within the agency.

Supporting Documentation

Drop files here or

Max. file size: 100 MB, Max. files: 5.

Photo Required: A high-resolution digital photo of the nominee must be included. Try to send a color photo (with good lighting) and just the nominee in it.*

Accepted file types: jpg, jpeg, png, gif.FileDescription

In your own words, please answer the following questions. Each answer should be 250 words or less.

1. What do you like most about being involved in EMS and what impact does that have on your community?*

2. How do you balance your schoolwork and other academic commitments, your EMS work and your other obligations?*

3. Do you plan to have continued involvement in EMS or in healthcare? Please explain your answer.*

4. If given the opportunity, what would you do to improve the EMS system in Virginia? How do you envision the improvement?*

I hereby certify that all information on this application is true and correct, and that the answers to the above questions were written entirely by me.*

Click box to certify that all information on this application is true and correct, and that the answers to the above questions were written entirely by applicant.

Regional Award for Outstanding Contribution to EMS by a Student NOMINATION FORM