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OMB: 1855-0015

# D.C. Opportunity Scholarship Program Application 

**School Year 2008-2009\
***Your Child's Future, Your Peace of Mind*

Thank you for your interest in the D.C. Opportunity Scholarship Program.
This form should be filled out by the parent or guardian who lives with
the child(ren) applying for a scholarship.

**[Scholarship Application and Contact Information]{.underline}**

> **Part A:** A description of the Program and your signed agreement to
> participate.
>
> **Part B:** Asks about the number of people in your household and
> other information needed to determine eligibility for the D.C.
> Opportunity Scholarship Program.
>
> **Part C:** Contact information for friends and family so that we can
> find you and/or your child/ren in case you move or change your phone
> number.

**Applying Parent/Guardian:**

+-----------------------------------------------------------------------+
| Parent/Guardian Name                                                  |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                         |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| Street Address                                                        |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\             |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| City \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ State |
| \_\_\_\_\_\_\_\_ Zip Code \_\_\_\_\_\_\_\_\_\_\_\_\_\_                |
|                                                                       |
| Home Phone Number (\_\_\_\_\_\_\_)                                    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Work Phone: (\_\_\_\_\_)       |
| \_\_\_\_\_\_\_\_\_                                                    |
|                                                                       |
| Mobile Phone (\_\_\_\_\_) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_    |
| E-Mail: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                |
+-----------------------------------------------------------------------+

  -----------------------------------------------------------------------
  NOTICE: According to the Paperwork Reduction Action of 1995, no persons
  are required to respond to a collection of information unless it
  displays a valid OMB Control Number. The valid OMB Control Number for
  this information collection is 1855-0015. The time required to complete
  this information collection is estimated at 20 minutes per respondent,
  including time to review instructions, and complete and review the
  information collection.

  -----------------------------------------------------------------------

**Part A. Description of the Program and Agreement to Participate**

**1. Description of the D.C. Opportunity Scholarship Program and
Evaluation**

The Opportunity Scholarship Program was authorized in early 2004 by the
U.S. Congress when they passed the DC School Choice Incentive Act. The
Program provides scholarships to enable low-income elementary and
secondary students to attend private schools though the 2008-2009 school
year.

-   Scholarships are for up to \$7,500 per year for tuition, fees (for
    example: books, uniforms, etc.), and transportation expenses. Under
    the current law, Congress has authorized the Program to run through
    the 2008-2009 school year.

-   Receiving a scholarship will not interfere in any way with any other
    public assistance your family may receive.

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-   Scholarships may only be used at a school participating in the D.C.
    Opportunity Scholarship Program.

-   If there are more applicants than slots in schools or available
    funds, the law requires that scholarships will be given out through
    a lottery.  The lottery will give priority to children attending
    schools identified as in need of improvement or corrective action. 
    Second priority will go to students from other public schools. 
    These priorities were written into the law that created this
    program.

-   Only families with completed applications will be included in the
    lottery. If your application is determined to be incomplete (meaning
    that we do not have enough documentation proving eligibility) we
    will contact you and give you a limited time in which to complete
    your application. **If you do not complete your application in time,
    we will not be able to include you in the lottery**. The
    determination of whether or not your application is complete is not
    made when you submit it. The determination of eligibility and if
    your application is complete is made by the Washington Scholarship
    Fund (WSF) once we have had time to review your submission in
    detail.

-   Once your child has a scholarship, you are responsible for applying
    to the schools that you are interested in. Each school has its own
    application process, and you must contact participating schools
    directly to apply.

-   Schools that you apply to will inform you whether or not each
    applicant is **admissible**. We will be matching children to their
    first choice schools in a lottery. If there are more children that
    have requested a particular grade in a particular school, we will
    hold a lottery to determine which children will get those spaces.
    Your child is not PLACED in a school for payment with their
    scholarship until WSF places them.

-   While application to the Program is voluntary, all applicants must
    participate in the Evaluation, whether or not they receive a
    scholarship. The Evaluation is important because it lets Congress
    know how successful the Program has been. As part of the Evaluation,
    applicants must agree to:

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-   Annual testing of your child

-   Parent surveys and voluntary focus groups where you will be asked
    your opinions

-   Surveys of children in grades 4 and above

-   Collection of files and records from your child's school

    -   If you have any questions about the application or your
        eligibility for the Program, please call the Washington
        Scholarship Fund at 202-222-0535, or at 1-888-DC-YOUTH.

**2. Agreement to Participate**

When the U.S. Congress created the D.C. Opportunity Scholarship Program,
it established rules for who is eligible to apply and how those
applications should be handled. This form is your agreement that you
understand these important requirements for the Program.

**In submitting this application, I agree to the following for each
child named below:**

-   To be eligible for participation in the D.C. Opportunity Scholarship
    Program, I must live in the District of Columbia and my annual
    household income must be below certain specified amounts. I certify
    that I am now a resident of the District of Columbia and will be for
    the 2008-2009 school year.

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-   I understand that, if eligible, my child's name will be placed in a
    lottery for a scholarship. My child may or may not receive a
    scholarship under this Program.

-   I understand that WSF must keep copies of all documents submitted
    during the application process to ensure that families are eligible.
    WSF will keep this data strictly confidential.

-   I understand that WSF will have access to my child's report cards
    while my child is participating in this program. This information
    will be held strictly confidential and will not be shared with
    anyone but designated WSF staff.

-   I consent to the disclosure of information about my child(ren) and
    me contained in this application to the U.S. Department of Education
    and its contractor(s) for the purposes of evaluating this program. I
    understand that the Department and its contractors will not release
    to anyone or any organization personally identifiable information in
    this application and evaluation questionnaire, except as required by
    law.

Parent/Guardian Name(print)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

First name Middle name Last name

Parent/Guardian Signature
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Today's Date
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Please list all children applying for a scholarship: Has this child
applied**

**for the OSP before?**

1.  Child's Name
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
    Yes No

> First name Middle name Last name

2.  Child's Name
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
    Yes No

> First name Middle name Last name

3.  Child's Name
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
    Yes No

> First name Middle name Last name

4.  Child's Name
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
    Yes No

> First name Middle name Last name

5.  Child's Name
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
    Yes No

> First name Middle name Last name

6.  Child's Name
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
    Yes No

> First name Middle name Last name

**Part B.**

B1. Do you live in the District of Columbia (D.C.)?

> Yes No (Please see a WSF staff member)

B2a. How many people live in your house?

  ------------------------------------------ ----------------------------
  Number of Adults                           

  Number of Children                         

                                             

  **Total**                                  
  ------------------------------------------ ----------------------------

B2b. How many of the children in your household have applied for and/or
received an Opportunity Scholarship before?

> \_\_\_\_\_\_\_\_ Number of children that applied for an Opportunity
> Scholarship
>
> \_\_\_\_\_\_\_\_ Number of children that received an Opportunity
> scholarship

B3. What language is spoken most often in your home? (Check one box.)

> English
>
> Spanish
>
> Vietnamese
>
> Hindi
>
> Amharic
>
> Another language (please list)
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

B4. How did you hear about the D.C. Opportunity Scholarship Program?

(Check all that apply)

> Family member or friend
>
> Newspaper article
>
> Radio
>
> Applied last year
>
> Letter from WSF
>
> Other (please list) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

B5. For all the adults in your house (listed in Questions B2a), fill out
the following table. (If there is not a 2^nd^ Adult in the house, you do
not need to fill in the Parent/Guardian B column.)

+--------------+----------------+------------------+------------------+
|              | **You**        | Parent/Guardian  | Other Adults\    |
|              |                | B\               | (Adult 3)        |
|              | (P             | (Adult 2)        |                  |
|              | arent/Guardian |                  |                  |
|              | A)             |                  |                  |
|              |                |                  |                  |
|              | (Adult 1)      |                  |                  |
+--------------+----------------+------------------+------------------+
| 1\. Name     |                |                  |                  |
| (First,      |                |                  |                  |
| Last)        |                |                  |                  |
+--------------+----------------+------------------+------------------+
| 2\. Social   | \_\_\_         | \_\_             | \_\_\_           |
| security     | \_\_-\_\_\_\_\ | \_\_\_-\_\_\_\_\ | \_\_\_-\_\_\_\_\ |
| number       | _\_-\_\_\_\_\_ | _\_-\_\_\_\_\_\_ | _\_-\_\_\_\_\_\_ |
+--------------+----------------+------------------+------------------+
| 3\. Date of  | \_\_\_\_/\_\_  | \_\_\_\_/\_      | \_\_\_\_/\_      |
| birth        | \_\_/\_\_\_\_\ | \_\_\_/\_\_\_\_\ | \_\_\_/\_\_\_\_\ |
|              | (mm/ dd/ yyyy) | (mm/ dd/ yyyy)   | (mm/ dd/ yyyy)   |
+--------------+----------------+------------------+------------------+
| 4\. Gender   | Male           | Male             | Male             |
|              |                |                  |                  |
|              | Female         | Female           | Female           |
+--------------+----------------+------------------+------------------+
| 5\.          |                | -   Spouse       | -   Spouse       |
| Relationship |                |                  |                  |
| to you       |                | -   Parent /     | -   Parent /     |
|              |                |     Stepparent   |     Stepparent   |
| (Par         |                |                  |                  |
| ent/Guardian |                | Boyfriend/       | Boyfriend/       |
| A/ Adult 1)  |                | Girlfriend       | Girlfriend       |
|              |                |                  |                  |
| (check one)  |                | Father-in-l      | Father-in-l      |
|              |                | aw/Mother-in-law | aw/Mother-in-law |
|              |                |                  |                  |
|              |                | Grandparent      | Grandparent      |
|              |                |                  |                  |
|              |                | Other relative   | Other relative   |
|              |                | or adult         | or adult         |
|              |                |                  |                  |
|              |                | Specify:         | Specify:         |
|              |                | \_               | \_               |
|              |                | \_\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_ |
|              |                | \_\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_ |
+--------------+----------------+------------------+------------------+
| 5\. Current  | Single, never  | Single, never    | Single, never    |
| Marital      | married        | married          | married          |
| status       |                |                  |                  |
| (check one)  | Married        | Married          | Married          |
|              |                |                  |                  |
|              | Widowed        | Widowed          | Widowed          |
|              |                |                  |                  |
|              | Divorced       | Divorced         | Divorced         |
|              |                |                  |                  |
|              | Divorced,      | Divorced,        | Divorced,        |
|              | remarried      | remarried        | remarried        |
|              |                |                  |                  |
|              | Separated      | Separated        | Separated        |
+--------------+----------------+------------------+------------------+
| 6\. Did your | No             | No               | No               |
| marital      |                |                  |                  |
| status       | Yes. If Yes,   | Yes. If Yes,     | Yes. If Yes,     |
| changed in   | check one:     | check one:       | check one:       |
| the past 12  |                |                  |                  |
| months?      | Divorced Date: | Divorced Date:   | Divorced Date:   |
|              |                |                  |                  |
|              | Month/Year     | Month/Year       | Month/Year       |
|              | \_\_           | \_               | \_               |
|              | \_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_ |
|              |                |                  |                  |
|              | Separated      | Separated Date:  | Separated Date:  |
|              | Date:          |                  |                  |
|              |                | Month/Year       | Month/Year       |
|              | Month/Year     | \_               | \_               |
|              | \_\_           | \_\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_ |
|              | \_\_\_\_\_\_\_ |                  |                  |
|              |                | Married Date:    | Married Date:    |
|              | Married Date:  |                  |                  |
|              |                | Month/Year       | Month/Year       |
|              | Month/Year     | \_               | \_               |
|              | \_\_           | \_\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_ |
|              | \_\_\_\_\_\_\_ |                  |                  |
+--------------+----------------+------------------+------------------+
| 7\. During   | Yes, all the   | Yes, all the     | Yes, all the     |
| the past 12  | time           | time             | time             |
| months, were |                |                  |                  |
| you the      | Yes, some of   | Yes, some of the | Yes, some of the |
| child's      | the time       | time             | time             |
| primary      |                |                  |                  |
| caretaker at | No, none of    | No, none of the  | No, none of the  |
| home?        | the time       | time             | time             |
+--------------+----------------+------------------+------------------+
| 8\. Is the   | Yes            | Yes              | Yes              |
| adult        |                |                  |                  |
| Hispanic or  | No             | No               | No               |
| Latino?      |                |                  |                  |
+--------------+----------------+------------------+------------------+

**Please note that if there are more than 3 adults living with the
child, you will need to fill out another copy of Question B5. You must
fill out Question B5 for every adult living with the child.**

**B5. Continued**

+--------------+------------------+-----------------+-----------------+
| **Adults,    | **You**          | Parent/Guardian | Other Adults\   |
| Continued**  |                  | B\              | (Adult 3)       |
|              | (Parent/Guardian | (Adult 2)       |                 |
|              | A)               |                 |                 |
|              |                  |                 |                 |
|              | (Adult 1)        |                 |                 |
+--------------+------------------+-----------------+-----------------+
| 9\. What is  | American Indian  | American Indian | American Indian |
| the adult's  | or Alaskan       | or Alaskan      | or Alaskan      |
| race? (you   | Native           | Native          | Native          |
| may check    |                  |                 |                 |
| more than    | Asian            | Asian           | Asian           |
| one box)     |                  |                 |                 |
|              | Black            | Black           | Black           |
|              |                  |                 |                 |
|              | Native Hawaiian  | Native Hawaiian | Native Hawaiian |
|              | or Other Pacific | or Other        | or Other        |
|              | Islander         | Pacific         | Pacific         |
|              |                  | Islander        | Islander        |
|              | White            |                 |                 |
|              |                  | White           | White           |
|              | Other:           |                 |                 |
|              |                  | Other:          | Other:          |
|              | \_\_\_\_\_\_\_\_ |                 |                 |
|              | \_\_\_\_\_\_\_\_ | \_\_\_\_\_      | \_\_\_\_\_\_    |
|              |                  | \_\_\_\_\_\_\_\ | \_\_\_\_\_\_\_\ |
|              |                  | _\_\_\_\_\_\_\_ | _\_\_\_\_\_\_\_ |
+--------------+------------------+-----------------+-----------------+
| 10\. What is | Less than high   | Less than high  | Less than high  |
| the adult's  | school           | school          | school          |
| highest      | graduation       | graduation      | graduation      |
| level of     |                  |                 |                 |
| education    | GED              | GED             | GED             |
| completed?   |                  |                 |                 |
|              | High school      | High school     | High school     |
|              | diploma          | diploma         | diploma         |
|              |                  |                 |                 |
|              | Some college or  | Some college or | Some college or |
|              | training, but    | training, but   | training, but   |
|              | did not earn a   | did not earn a  | did not earn a  |
|              | degree or        | degree or       | degree or       |
|              | certificate      | certificate     | certificate     |
|              |                  |                 |                 |
|              | Degree or        | Degree or       | Degree or       |
|              | certificate from | certificate     | certificate     |
|              | a 2-year or less | from a 2-year   | from a 2-year   |
|              | than 2-year      | or less than    | or less than    |
|              | college/\        | 2-year          | 2-year          |
|              | training program | college/\       | college/\       |
|              |                  | training        | training        |
|              | Bachelor's       | program         | program         |
|              | degree           |                 |                 |
|              |                  | Bachelor's      | Bachelor's      |
|              | Graduate         | degree          | degree          |
|              | (post-BA) degree |                 |                 |
|              |                  | Graduate        | Graduate        |
|              | Don't know       | (post-BA)       | (post-BA)       |
|              |                  | degree          | degree          |
|              |                  |                 |                 |
|              |                  | Don't know      | Don't know      |
+--------------+------------------+-----------------+-----------------+
| 11\. Does    | Yes, a full-time | Yes, a          | Yes, a          |
| the adult    | job (35+ hours)  | full-time job   | full-time job   |
| currently    |                  | (35+ hours)     | (35+ hours)     |
| have a job   | Yes, a part-time |                 |                 |
| outside the  | job (less than   | Yes, a          | Yes, a          |
| house,       | 35 hours)        | part-time job   | part-time job   |
| either       |                  | (less than 35   | (less than 35   |
| full-time or | Not working now, | hours)          | hours)          |
| part-time?   | but looking for  |                 |                 |
|              | work             | Not working     | Not working     |
|              |                  | now, but        | now, but        |
|              | Not working now  | looking for     | looking for     |
|              | and not looking  | work            | work            |
|              | for work         |                 |                 |
|              |                  | Not working now | Not working now |
|              | Don't know       | and not looking | and not looking |
|              |                  | for work        | for work        |
|              |                  |                 |                 |
|              |                  | Don't know      | Don't know      |
+--------------+------------------+-----------------+-----------------+
| 12\. Since   | > \_\_\_\_\_     | > \_\_\_\_\_    | > \_\_\_\_\_    |
| you began    | > years          | > years         | > years         |
| working as   |                  |                 |                 |
| an adult,    |                  |                 |                 |
| about how    |                  |                 |                 |
| many years   |                  |                 |                 |
| have you     |                  |                 |                 |
| worked?      |                  |                 |                 |
+--------------+------------------+-----------------+-----------------+
| 13\. Does    |                  | Yes             | Yes             |
| this person  |                  |                 |                 |
| contribute   |                  | No              | No              |
| to your or   |                  |                 |                 |
| your         |                  |                 |                 |
| family's     |                  |                 |                 |
| expenses?    |                  |                 |                 |
+--------------+------------------+-----------------+-----------------+

**Please note that if there are more than 3 adults living with the
child, you will need to fill out another copy of Question B5. You must
fill out Question B5 for every adult living with the child.**

B6. Fill out the following table for each child that is [applying for a
scholarship under the D.C. Opportunity Scholarship Program]{.underline}.
If you are applying for more than three children, please note that the
form for additional children is continued on the next page.

+----------------+-----------------+----------------+-----------------+
|                | **Child 1**     | **Child 2**    | **Child 3**     |
+================+=================+================+=================+
| 1.  Child's    |                 |                |                 |
|     Name       |                 |                |                 |
|                |                 |                |                 |
| > (First,      |                 |                |                 |
| > Last)        |                 |                |                 |
+----------------+-----------------+----------------+-----------------+
| 2\. Social     | \_\_\_\_-\_\_   | \_\_\_\_-\_\_\ | \_\_\_\_-\_\_   |
| security       | \_\_-\_\_\_\_\_ | _\_-\_\_\_\_\_ | \_\_-\_\_\_\_\_ |
| number         |                 |                |                 |
+----------------+-----------------+----------------+-----------------+
| 3\. Date of    | \_\_\_\_/\_\    | \_\_\_\_/\_\_  | \_\_\_\_/\_\    |
| birth          | _\_\_/\_\_\_\_\ | \_\_/\_\_\_\_\ | _\_\_/\_\_\_\_\ |
|                | (mm/ dd/ yyyy)  | (mm/ dd/ yyyy) | (mm/ dd/ yyyy)  |
+----------------+-----------------+----------------+-----------------+
| 4\. Gender     | Male            | Male           | Male            |
|                |                 |                |                 |
|                | Female          | Female         | Female          |
+----------------+-----------------+----------------+-----------------+
| 5\.            | son/daughter    | son/daughter   | son/daughter    |
| Relationship   |                 |                |                 |
| to You         | foster child    | foster child   | foster child    |
| (P             |                 |                |                 |
| arent/Guardian | grandso         | grandson       | grandso         |
| A/ Adult 1)    | n/granddaughter | /granddaughter | n/granddaughter |
|                |                 |                |                 |
| > (check one)  | niece/nephew    | niece/nephew   | niece/nephew    |
|                |                 |                |                 |
|                | Other:          | Other:         | Other:          |
|                | \_              | \_\_\_\_\_\_\_ | \_              |
|                | \_\_\_\_\_\_\_\ | \_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\ |
|                | _\_\_\_\_\_\_\_ |                | _\_\_\_\_\_\_\_ |
+----------------+-----------------+----------------+-----------------+
| 6\. Is the     | Yes             | Yes            | Yes             |
| child Hispanic |                 |                |                 |
| or Latino?     | No              | No             | No              |
+----------------+-----------------+----------------+-----------------+
| 7\. What is    | American Indian | American       | American Indian |
| the child's    | or Alaskan      | Indian or      | or Alaskan      |
| race? (you may | Native          | Alaskan Native | Native          |
| check more     |                 |                |                 |
| than one box)  | Asian           | Asian          | Asian           |
|                |                 |                |                 |
|                | Black           | Black          | Black           |
|                |                 |                |                 |
|                | Native Hawaiian | Native         | Native Hawaiian |
|                | or Other        | Hawaiian or    | or Other        |
|                | Pacific         | Other Pacific  | Pacific         |
|                | Islander        | Islander       | Islander        |
|                |                 |                |                 |
|                | White           | White          | White           |
|                |                 |                |                 |
|                | Other:          | Other:         | Other:          |
|                | \_              | \_\_\_\_\_\_\_ | \_              |
|                | \_\_\_\_\_\_\_\ | \_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\ |
|                | _\_\_\_\_\_\_\_ |                | _\_\_\_\_\_\_\_ |
+----------------+-----------------+----------------+-----------------+
| 8\. Name of    |                 |                |                 |
| school         |                 |                |                 |
| currently      |                 |                |                 |
| attending      |                 |                |                 |
| (2007-2008     |                 |                |                 |
| school year)   |                 |                |                 |
+----------------+-----------------+----------------+-----------------+
| 9\. Type of    | Public school   | Public school  | Public school   |
| school         |                 |                |                 |
| currently      | Charter school  | Charter school | Charter school  |
| attending      | (Public)        | (Public)       | (Public)        |
|                |                 |                |                 |
|                | Private school  | Private school | Private school  |
|                |                 |                |                 |
|                | -   Private     | -   Private    | -   Private     |
|                |     school      |     school     |     school      |
|                |     funded by   |     funded by  |     funded by   |
|                |     DCPS        |     DCPS       |     DCPS        |
|                |                 |                |                 |
|                | -   Daycare/not | -              | -   Daycare/not |
|                |     yet in      |    Daycare/not |     yet in      |
|                |     school      |     yet in     |     school      |
|                |                 |     school     |                 |
+----------------+-----------------+----------------+-----------------+
| 10\. Current   |                 |                |                 |
| grade          |                 |                |                 |
| (2007-2008     |                 |                |                 |
| school year)   |                 |                |                 |
+----------------+-----------------+----------------+-----------------+
| 11\. Does the  | Yes             | Yes            | Yes             |
| child have an  |                 |                |                 |
| IEP? (This     | No              | No             | No              |
| will **NOT**   |                 |                |                 |
| affect their   | Don't know/Not  | Don't know/Not | Don't know/Not  |
| chance for a   | sure            | sure           | sure            |
| scholarship)   |                 |                |                 |
+----------------+-----------------+----------------+-----------------+
| 12\. Does the  | Physical        | Physical       | Physical        |
| child have any | disability      | disability     | disability      |
| of the         |                 |                |                 |
| following      | Diagnosed       | Diagnosed      | Diagnosed       |
| challenges?    | learning        | learning       | learning        |
| (This will     | disability      | disability     | disability      |
| **NOT** affect |                 |                |                 |
| their chance   | Problems        | Problems       | Problems        |
| for a          | understanding   | understanding  | understanding   |
| scholarship)   | English         | English        | English         |
+----------------+-----------------+----------------+-----------------+

**Please note that Question B6 continues on the next page for child 4,
child 5, and child 6.**

B6. Continued for child 4, child 5, and child 6:

+---------------+-----------------+-----------------+-----------------+
| **Child,      | **Child 4**     | **Child 5**     | **Child 6**     |
| continued**   |                 |                 |                 |
+===============+=================+=================+=================+
| 1\. Child's   |                 |                 |                 |
| Name          |                 |                 |                 |
|               |                 |                 |                 |
| > (First,     |                 |                 |                 |
| > Last)       |                 |                 |                 |
+---------------+-----------------+-----------------+-----------------+
| 2\. Social    | \_\_\_\_-\_\_   | \_\_\_\_-\_\_   | \_\_\_\_-\_\_   |
| security      | \_\_-\_\_\_\_\_ | \_\_-\_\_\_\_\_ | \_\_-\_\_\_\_\_ |
| number        |                 |                 |                 |
+---------------+-----------------+-----------------+-----------------+
| 3\. Date of   | \_\_\_\_/\_\    | \_\_\_\_/\_\    | \_\_\_\_/\_\    |
| birth         | _\_\_/\_\_\_\_\ | _\_\_/\_\_\_\_\ | _\_\_/\_\_\_\_\ |
|               | (mm/ dd/ yyyy)  | (mm/ dd/ yyyy)  | (mm/ dd/ yyyy)  |
+---------------+-----------------+-----------------+-----------------+
| 4\. Gender    | Male            | Male            | Male            |
|               |                 |                 |                 |
|               | Female          | Female          | Female          |
+---------------+-----------------+-----------------+-----------------+
| 5\.           | son/daughter    | son/daughter    | son/daughter    |
| Relationship  |                 |                 |                 |
| to You        | foster child    | foster child    | foster child    |
| (Pa           |                 |                 |                 |
| rent/Guardian | grandso         | grandso         | grandso         |
| A/ Adult 1)   | n/granddaughter | n/granddaughter | n/granddaughter |
|               |                 |                 |                 |
| > (check one) | niece/nephew    | niece/nephew    | niece/nephew    |
|               |                 |                 |                 |
|               | Other:          | Other:          | Other:          |
|               | \_              | \_\_\_\_\_\_\   | \_              |
|               | \_\_\_\_\_\_\_\ | _\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\ |
|               | _\_\_\_\_\_\_\_ |                 | _\_\_\_\_\_\_\_ |
+---------------+-----------------+-----------------+-----------------+
| 6\. Is the    | Yes             | Yes             | Yes             |
| child         |                 |                 |                 |
| Hispanic or   | No              | No              | No              |
| Latino?       |                 |                 |                 |
+---------------+-----------------+-----------------+-----------------+
| 7\. What is   | American Indian | American Indian | American Indian |
| the child's   | or Alaskan      | or Alaskan      | or Alaskan      |
| race? (you    | Native          | Native          | Native          |
| may check     |                 |                 |                 |
| more than one | Asian           | Asian           | Asian           |
| box)          |                 |                 |                 |
|               | Black           | Black           | Black           |
|               |                 |                 |                 |
|               | Native Hawaiian | Native Hawaiian | Native Hawaiian |
|               | or Other        | or Other        | or Other        |
|               | Pacific         | Pacific         | Pacific         |
|               | Islander        | Islander        | Islander        |
|               |                 |                 |                 |
|               | White           | White           | White           |
|               |                 |                 |                 |
|               | Other:          | Other:          | Other:          |
|               | \_\_\_\_\_\_\   | \_\_\_\_\_\_\_\ | \_              |
|               | _\_\_\_\_\_\_\_ | _\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\ |
|               |                 |                 | _\_\_\_\_\_\_\_ |
+---------------+-----------------+-----------------+-----------------+
| 8\. Name of   |                 |                 |                 |
| school        |                 |                 |                 |
| currently     |                 |                 |                 |
| attending     |                 |                 |                 |
| (2007-2008    |                 |                 |                 |
| school year)  |                 |                 |                 |
+---------------+-----------------+-----------------+-----------------+
| 9\. Type of   | Public school   | Public school   | Public school   |
| school        |                 |                 |                 |
| currently     | Charter school  | Charter school  | Charter school  |
| attending     | (Public)        | (Public)        | (Public)        |
|               |                 |                 |                 |
|               | Private school  | Private school  | Private school  |
|               |                 |                 |                 |
|               | -   Private     | -   Private     | -   Private     |
|               |     school      |     school      |     school      |
|               |     funded by   |     funded by   |     funded by   |
|               |     DCPS        |     DCPS        |     DCPS        |
|               |                 |                 |                 |
|               | -   Daycare/not | -   Daycare/not | -   Daycare/not |
|               |     yet in      |     yet in      |     yet in      |
|               |     school      |     school      |     school      |
+---------------+-----------------+-----------------+-----------------+
| 10\. Current  |                 |                 |                 |
| grade         |                 |                 |                 |
| (2007-2008    |                 |                 |                 |
| school year)  |                 |                 |                 |
+---------------+-----------------+-----------------+-----------------+
| 11\. Does the | Yes             | Yes             | Yes             |
| child have an |                 |                 |                 |
| IEP? (This    | No              | No              | No              |
| will **NOT**  |                 |                 |                 |
| affect their  | Don't know/Not  | Don't know/Not  | Don't know/Not  |
| chance for a  | sure            | sure            | sure            |
| scholarship)  |                 |                 |                 |
+---------------+-----------------+-----------------+-----------------+
| 12\. Does the | Physical        | Physical        | Physical        |
| child have    | disability      | disability      | disability      |
| any of the    |                 |                 |                 |
| following     | Diagnosed       | Diagnosed       | Diagnosed       |
| challenges?   | learning        | learning        | learning        |
| (This will    | disability      | disability      | disability      |
| **NOT**       |                 |                 |                 |
| affect their  | Problems        | Problems        | Problems        |
| chance for a  | understanding   | understanding   | understanding   |
| scholarship)  | English         | English         | English         |
+---------------+-----------------+-----------------+-----------------+

**Note: If you are applying for scholarships for more than six children,
you will need to fill out an additional copy of B6 to provide the
required information.**

B7. How many people in your house are part of your household (economic
unit)?

> \_\_\_\_\_\_\_\_ Number of adults that contribute to your expenses or
> that you support
>
> \_\_\_\_\_\_\_\_ Number of children that you support

\_\_\_\_\_\_\_\_ **Total**

B8. Did you file an income tax return for 2006?

> Yes
>
> No

For the adults in Question B7, fill in the amount of income in 2006 for
each source of income in the table below.

+-----------------------------+-------------+-------------+------------+
| **Source of Income**        | **You**     | **Pare      | **Other    |
|                             |             | nt/Guardian | Adults\    |
|                             | **(Parent/  | B\          | (Adult     |
|                             | Guardian    | (Adult 2)** | 3)**       |
|                             | A)\         |             |            |
|                             | (Adult 1)** |             |            |
+-----------------------------+-------------+-------------+------------+
| a\. Adjusted gross income   | \$          | \$          | \$         |
| from 2006 tax return        |             |             |            |
+-----------------------------+-------------+-------------+------------+
| b\. Total wages, salaries,  | \$          | \$          | \$         |
| tips                        |             |             |            |
|                             |             |             |            |
| (if you did not file taxes) |             |             |            |
+-----------------------------+-------------+-------------+------------+
| c\. Social security income  | \$          | \$          | \$         |
| (include any SSI            |             |             |            |
|                             |             |             |            |
| you get for dependent       |             |             |            |
| children)                   |             |             |            |
+-----------------------------+-------------+-------------+------------+
| d\. Disability income       | \$          | \$          | \$         |
+-----------------------------+-------------+-------------+------------+
| e\. TANF/public assistance  | \$          | \$          | \$         |
+-----------------------------+-------------+-------------+------------+
| f\. Child support received  | \$          | \$          | \$         |
+-----------------------------+-------------+-------------+------------+
| g\. Gifts from              | \$          | \$          | \$         |
| family/friends              |             |             |            |
+-----------------------------+-------------+-------------+------------+
| h\. Interest and dividend   | \$          | \$          | \$         |
| income                      |             |             |            |
+-----------------------------+-------------+-------------+------------+
| i\. Tax refund receive in   | \$          | \$          | \$         |
| 2006                        |             |             |            |
+-----------------------------+-------------+-------------+------------+
| j\. Other income            | \$          | \$          | \$         |
+-----------------------------+-------------+-------------+------------+
| k\. Total                   | \$          | \$          | \$         |
+-----------------------------+-------------+-------------+------------+

B9. Total the amount of household income. To get this number, add the
amounts in the gray boxes from the table above in Question B8:

\$ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  --------------------------------- --------- ------------------------------
  **GUIDELINE TABLE**                         

  Number in Household               Maximum   
                                    Annual    
                                    Income    

  1                                           18,889

  2                                           25,327

  3                                           31,765

  4                                           38,203

  5                                           44,641

  6                                           51,079

  7                                           57,517

  8                                           63,955
  --------------------------------- --------- ------------------------------

B10. Using the Guideline Table to the right, the total number of people
in your household in Question B7, and the total household income in
Question B9 on page 9, is your household's total income at or below the
guideline for your household's size? If your household's income was
below \$18,889, be sure to check **Yes**.

> Yes (Go to B12)
>
> No (Go to B11)

B11. If you feel that the income in 2006 is not representative of your
current financial situation, please complete the table below with any
changes in employment or income status for all adults that affected
their income for 2007. You may be asked to provide documentation from
your employer or a government agency to confirm these changes.

+-----------------+---------------+-----------------+-----------------+
|                 | **You**       | Parent/Guardian | Other Adults\   |
|                 | (Pa           | B\              | (Adult 3)       |
|                 | rent/Guardian | (Adult 2)       |                 |
|                 | A) (Adult 1)  |                 |                 |
+-----------------+---------------+-----------------+-----------------+
| Type of Change  | Retired       | Retired         | Retired         |
|                 |               |                 |                 |
| (Check all that | Laid Off/Quit | Laid Off/Quit   | Laid Off/Quit   |
| apply)          |               |                 |                 |
|                 | Gone on       | Gone on         | Gone on         |
|                 | disability    | disability      | disability      |
|                 |               |                 |                 |
|                 | Found New Job | Found New Job   | Found New Job   |
|                 |               |                 |                 |
|                 | Promotion/    | Promotion/      | Promotion/      |
|                 | Raise         | Raise           | Raise           |
|                 |               |                 |                 |
|                 | Other         | Other           | Other           |
|                 |               |                 |                 |
|                 | Specify       | Specify         | Specify         |
|                 | \_\_\_\_\     | \_\_\_\         | \_\_\_\         |
|                 | _\_\_\_\_\_\_ | _\_\_\_\_\_\_\_ | _\_\_\_\_\_\_\_ |
+-----------------+---------------+-----------------+-----------------+
| Did this change | Higher by \$  | Higher by \$    | Higher by \$    |
| make your       | \_\_\_\_\_\_  | \_\_\_\_\_\_    | \_\_\_\_\_\_    |
| income for 2007 |               |                 |                 |
| higher or lower | Lower by      | Lower by        | Lower by        |
| than in 2006?   | \$\           | \               | \               |
|                 | _\_\_\_\_\_\_ | $\_\_\_\_\_\_\_ | $\_\_\_\_\_\_\_ |
+-----------------+---------------+-----------------+-----------------+

B12. Do you rent or own your residence?

> Rent Own Live with friend/relative

B13. What is your monthly rent or mortgage? Total \$\_\_\_\_\_\_\_\_ per
month

> Amount paid by you or your household \$\_\_\_\_\_\_\_\_\_ per month
>
> Amount paid by other source(s) \$\_\_\_\_\_\_\_\_\_ per month
>
> Other Source is: Section 8 or housing voucher
>
> Relative
>
> Friend
>
> Other: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

B14. How long have you lived at your current address?

> \_\_\_\_\_\_\_\_ years and \_\_\_\_\_\_\_\_ months

**Certification Signature**

**I certify** that all information on this application and ALL
supporting documentation are **true**, **correct**, **and complete** to
the best of my knowledge and ALL household income has been reported. **I
understand that deliberate misrepresentation of the information or
documentation will result in the scholarship being denied or revoked,
and may subject me to prosecution under District and Federal laws.**

  ------------------------- --- ------------------------- --- -------------
                                                              

  Parent/Guardian Name          Signature                     Date
  (Print)                                                     
  ------------------------- --- ------------------------- --- -------------

**Part C. Additional Contact Information**

Please provide the names and addresses for three people who are likely
to know the whereabouts of you and/or the child in the future. The
contact people listed do not have to be family members and can be
friends and/or neighbors of the family.

**Contact Information for:**

Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Home Phone Number (\_\_\_\_\_\_\_)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Work Phone: (\_\_\_\_\_)
\_\_\_\_\_\_\_\_\_

Mobile Phone (\_\_\_\_\_) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
E-Mail: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Relationship to you (Parent/Guardian):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Contact Information for:**

Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Home Phone Number (\_\_\_\_\_\_\_)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Work Phone: (\_\_\_\_\_)
\_\_\_\_\_\_\_\_\_

Mobile Phone (\_\_\_\_\_) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
E-Mail: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Relationship to you (Parent/Guardian):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Contact Information for:**

Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Home Phone Number (\_\_\_\_\_\_\_)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Work Phone: (\_\_\_\_\_)
\_\_\_\_\_\_\_\_\_

Mobile Phone (\_\_\_\_\_) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
E-Mail: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Relationship to you (Parent/Guardian):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_