Cheryl Kiefer Memorial Scholarship Application

Name:  _____________________________________________  Date ____/____/_____

Address:  _______________________________________________________________

                      (Street, City, State, Zip)

Date of Birth: ____/_____/_____   Last Grade Completed: ______________________

**Please attach a copy of your last transcript from High School or College

Why do you want to become an Emergency Medical Technician?  ________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Please explain your financial need for this scholarship:   ________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Are you currently employed?  _______________________________________________

_________________________________________________________________________

_________________________________________________________________________

What is your income?    _____________________________________________________

_________________________________________________________________________

**Please feel free to attach any additional information that could help the committee with the selection process.

Please print, complete and mail this application to: Huron Valley Ambulance, Cheryl Kiefer Memorial Scholarship,

Attention:  Shaun Pochik

1200 State Circle, Ann Arbor, MI  48108