First Responder Counseling Scholarship Application

First Responder Counseling Scholarship Application Form

For Graduate Students in Counseling or Psychology Degree Programs
I. Personal Data:

Tell us about yourself
Full Name*

PrefixFirst NameMiddle NameLast NameSuffix
Birth Date:*

MonthDayYear
E-mail :*
Where the confirmation will be sent to
Home Address :*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender:

MaleFemale
Are you a US citizen?*

YesNo
First Responder Experience:*

0/500
II. Undergraduate Information:
Did you have complete your bachelor degree during or before May 2025?*

YesNo
Undergraduate School where diploma was received:*
Year of Undergraduate Graduation:*
III. GPA Information:
GPA composite?*
VI. Graduate Degree Seeking Questions:
Please check each of the qualifiers below that apply to you. This data may increase your likelihood of qualifying for the scholarship.
Have you been accepted to a Masters in Counseling or Doctorate in Psychology or Philosophy degree program?*

YesNo
College you plan to attend:*
Degree Program you plan to achieve:*
Is the University's degree program you are enrolling in a Council for Accreditation of Counseling and Related Educational Programs (CACREP) Accredited Program or American Psychological Association (APA) accredited?*

YesNo
Have you, or will you, receive other scholarships?*

YesNo
If you answered yes, please indicate the amount of scholarship money that you will receive. Check all that apply*

$500 or less$500-$1500partial tuitionfull tuitionfull tuition, room and board, and booksother
Do you qualify for financial aid?*

YesNo
Do you plan to attend the university as a full time or part time student?*

YesNo
Since this scholarship will only cover partial payment of your tuition, how do you plan to pay for the remainder of your tuition?*

0/500
What quarter and year do you plan to start your practicum?:*
If you are a recipient of this grant, do you agree to complete your academic practicum and internship requirements with Status Code 4, Inc.?*

YesNo
What year do you plan to Graduate?:*
VII. Essay
Your essay should be 300-500 words. You should address in your essay: your college goals and choice of major, what you intend to do with your education, and why a scholarship is important to you. Include any academic and non-academic accomplishments, personal characteristics, or experiences that make you uniquely worthy of scholarship consideration.
Essay:*

0/500
VIII. Applicant's E-Signature
E-Signature:*
Today's Date:*

MonthDayYear
Date
Should be Empty:

First Responder Counseling Scholarship Application Form

I. Personal Data:

II. Undergraduate Information:

III. GPA Information:

VI. Graduate Degree Seeking Questions:

VII. Essay

VIII. Applicant's E-Signature