First Responder Training Scholarship Application - Dodge County Community Foundation

upon least Training

Name *

First

Last

Home Address *

Phone number *

Email *

Name of First Responder Training School *

Certification *

Select which type of emergency response certification you are pursuing.

Describe why you are interested in emergency response services. *

Responses should be 1-2 paragraphs.

Years I plan to volunteer as first responder upon training completion:

Selected Value: 1

This scholarship has a minimum requirement of volunteering for 12 months after successful completion of training and certification.

I certify that I intend to volunteer in Dodge County as a first responder for at least 12 months. *

Where will you volunteer after certification? *

i.e. Dodge Center Ambulance, Hayfield Ambulance, West Concord Ambulance, Mantorville Fire Department, etc.

Reference *

First

Last

A letter of support is required from an authorized representative of the first responder service you intend to volunteer at after successful completion of training and certification.

Reference Letter *

I have emailed a PDF of the reference letter to [email protected]
My reference has emailed a copy of their reference letter to [email protected]

Your reference letter must be received by DCCF for your application to be considered complete. You may also mail a hard copy of the reference letter to: DCCF Attention: Scholarships, PO Box 23, Kasson, MN 55944.

I agree to the following statement: *

I (or we), the applicant, agree to indemnify, defend, and hold harmless DCCF, its board of directors, officers, and its agents from and against any liability or loss arising from this application, any grant award should one be forthcoming to applicant, agreements arising out of such a grant, and/or ongoing engagement with DCCF, unless such liability or loss is the result of DCCF’s sole negligence or willful misconduct.

I agree to: *

Authorization of DCCF to use project and applicant information for marketing, donor relations, communications, accounting, and tax reporting.

I agree to: *

Provide follow-up reporting satisfactory to DCCF regarding project completion and impact, and will make every reasonable effort to provide documentation requested by DCCF and/or its agents within a reasonable timeframe not to exceed 90 days following receipt of the request.