Back Your Badge Scholarship Application Round 2 Name* First M.I Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*Phone*Email* DOB* Month Day Year Ethnicity Hispanic or Latino Not Hispanic or Latino Race American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Asian White Black or African American Other If other, please specify.Are you currently certified in Indiana as an EMT?* Yes No Are you currently employed as an EMT?* Yes No When do you plan to enroll in a paramedic program?*What training program/school are you attending or plan to attend?*Have you been accepted into a Paramedic Program?* Yes No How much will the program cost or what are your remaining costs? (if unknown, please state "unknown")*Where is your intended program located?*Do you have a high school diploma and/or equivalent?* Yes No How would this scholarship benefit you in completing a Paramedic Science program and why are you interested in this profession? (Please briefly answer each question with a minimum of 100 characters and maximum of 500 characters)*
