Green County Ems of Monroe (f)

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ENTRY FORMGREEN COUNTY EMS OF MONROE SCHOLARSHIP APPLICATION

STUDENT'S NAME:STUDENT'S HOME ADDRESS:City: State: Zip Code:Telephone: (608) Social Security No.:STUDENT'S HIGH SCHOOL: Monroe High SchoolHIGH SCHOOL ADDRESS: 1600 26

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StreetCity : Monroe State: WI Zip Code: 53566Telephone: (608) 328-7118Student's Signature: Date:Principal orCounselor's Signatures Date:College, university or other educational institution student plans to attend (Indicate name of schooland address):First Choice:Second Choice:

The scholarship will be paid on proof of enrollment in the second academic year.

I. Financial Need - In the space provided please indicate your family’s adjusted gross income fromtheir last tax return:Under $15,000 $30,000 to $35,000$15,000 to $20,000 $35,000 to $50,000$20,000 to $25,000 over $50,000$25,000 to $30,000Total number of family members living at home:Number of dependants in your parents’ family including yourself:Children Ages No. Attending CollegeOther financial considerations which need to be noted:II. Extracurricular Activities: Organizations and Clubs (Show years of involvement; also, pleaseindicate any office held.)Honors and Awards:Community or Other Activities:III. Work Activities: Are you now employed? Yes NoIf yes, what type of work and how many hours per week?Describe you other work activities (such as family farm, helping at home, family business):

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