Fillable Geoffrey T. Corbin EMS Scholarship Application (Billings Clinic)

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Geoffrey T. Corbin EMS Scholarship Application (Billings Clinic)

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Geoffrey T. Corbin
EMS Scholarship Application
2020 Scholarship Application Form
Application Deadline End of Business Day, January 22, 2021.
To be eligible for consideration, all documents must be submitted
in the format as shown on this application.
*Please save this
application to your computer before you begin.
NAME: DOB:
Last First Middle
ADDRESS:
Street City ST ZIP
Primary Phone # Email
EDUCATION:
High School City Graduation Year
High School Cumulative GPA*
COLLEGE:
Name of college City ST ZIP
Expected Graduation Date (MM/YY)
College Cumulative GPA*
TYPE OF EMT/Paramedic Program: (check one)
□ Big Sky EMS Symposium
□ Vocational/Technical School EMS program
□ Two Year Junior or Community College
□ Other EMT & EMR Training (Please list program) ____________________
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Type of EMS Career you are pursuing: (check one)
□ Dispatcher
□ Emergency Medical Responder (EMR)
□ Emergency Medical Technician (EMT)
□ Advanced Emergency Medical Technician
□ Paramedic
□ Other: (Please list)
Have you been accepted into an EMS program?
Program dates:
Cost of program:
Yes
- 3 -
WORK EXPERIENCE: Describe your work and volunteer experience during the past three (3)
years and how this will help you in the Emergency Medical Services (EMS) fields. No
attachments accepted.
Company Name/Address Position Date (from/to)
Please use this space to share if there is something unique about you or your family that
you would want the scholarship committee to know as they consider your application.
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In 250 words or less, why do you want to pursue a career in Emergency Medical Services
(EMS) and what qualities do you possess to succeed in your chosen career?
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All applicants sign below:
I certify that the information provided is complete and accurate to the best of my
knowledge.
Applicant's Signature Date
(Your Electronic signature represents an original signature for this purpose)
Please submit in an email in one package:
One (1) copy of this completed application with your original signature.
• To save this application with your information: Download the PDF application to your
computer. Fill out application. Save a copy to your computer. Attach the saved document
with your information to the email.
One (1) copy of most recent official high school transcript or G.E.D. and current college transcript,
if applicable. (Non-official transcripts are acceptable and may be an electronic version)
Please email complete package to the following email address.
spratt@billingsclinic.org
Or
Mail complete package to the following address.
Scholarship Committee
Billings Clinic Foundation
PO Box 31031
Billings, MT 59107
Scholarships are awarded to Individuals who exhibit a strong desire and the potential to excel in
the health care field.
Must be postmarked by January 22, 2021. Late or incomplete applications will not be
considered.
Equal Opportunity: Billings Clinic Foundation awards scholarships without regard to race, religion,
creed, age, sex or national origin.
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Geoffrey T. Corbin EMS Scholarship Application (Billings Clinic)

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Completed 31 January 2021

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