### Household Number : « HH »

Scholarship Application – ( SY 2012 -13 )

– Parts A and B

D.C. Opportunity Scholarship Program Page 1 of 9 

# Scholarship Application

D.C. Opportunity Scholarship Program

20 12-13

Thank you for your interest in the D.C. Opportunity Scholarship Program (OSP). This application should be filled out by the

parent or guardian who lives with the child(ren) applying for a scholarship.

Part A A greement to P articipate

Part B Information needed to determine eligibility for D.C. Opportunity Scholarship Program

Part C Current school information for each student applicant (form for one student attached)



### 1. Applicant Name(s)

List the name of parent/guardian and all children applying for a D.C. Opportunity Scholarship.



### Parent/Guardian (You)

First Middle Last

First Middle Last DOB (mm/dd/yy)



### Child #1 

## / /

Child #2 

## / /

Child #3 

## / /

Child #4 

## / /

Child # 5 

## / /

Child # 6 

## / /

NOTICE: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless su ch

collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to aver age 25

minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data

needed, and completing and reviewing the collection of information. The obligation to respond to this collection is mandatory according

to PL 108 199 Sec. 3 (Title III). Send comments regarding the burden estimate or any other aspect of this collection of infor mation,

including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Ave. , SW, Washington, DC 20210

-

4537 or email ICDocketMgr@ed.gov and reference the OMB Control Number 1855

- 0015. Note: Please do not return the completed

scholarship application to this address. 

### 2. Have you ever applied before to the OSP for any of your child(ren)?



#  Yes 

#  No 

#  Not sure OMB: 1855

- 001 5

FOR TRUST USE ONLY

Date:

Location:

Initials:

### Household Number: « HH »

Scholarship Application – ( SY 2012 -13 )

– Parts A and B

D.C. Opportunity Scholarship Program Page 2 of 9 

# Part A: Agreement to Participate

**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. Congress also required that an evaluation

be conducted to study the Program and students’ experiences before, during , and after being part of the

Program. 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 r esident of the

District of Columbia and will be for the 201 2-13 school year.

• I understand that, if eligible, my child’s name will be placed in a lottery for a scholarship. I also understand my

child(ren) may or may not receive a scholarship under this Pro gram.

• I understand that the Trust must keep copies of all documents submitted during the application process to ensure

that families are eligible. The Trust will keep this data strictly confidential.

• I understand that the Trust 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 Trust staff.

• I understand that my child and I are required to participate in all aspects of the evaluation, including the annual

testing of my child, filling out annual surveys, and allowing records to be collected from my child’s school. If my child

and I do not participate in these evaluation activities, my child will not be eligible for a scholarship in any year.

• 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

De partment and its contractors will not release to anyone or any organization personally identifiable information in

this application, except as required by law.

Signature Parent/Guardian Name (Print) Date



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

Check all that apply



#  Family Member or Friend 

#  Applied to OSP Before



#  Letter/Flyer from the Trust 

#  School



#  Newspaper Article, Ad, or Metro 

#  OSP Website



#  Community Organization 

#  Representative from the Trust



#  Radio 

#  Other :



### 2. What language is spoken most often in your home?



#  English 

#  Spanish



#  Amharic 

#  Hindi/Urdu



#  Vietnamese 

#  Other :

### Household Number : « HH »

Scholarship Application – ( SY 2012 -13 )

– Parts A and B

D.C. Opportunity Scholarship Program Page 3 of 9 

# Part B: Scholarship Application

**Instructions**

• Fill out all pages of this form

– do not leave any questions blank

• Submit additional documents at Trust offic e, fax (202.478.0991), or email info@dcscholarships.org

• You will receive a letter in the mail with the status of your application

• Please a llow 10

- 15 business days for processing

1. Residency and Contact Information

Fill in contact information for applying parent/guardian (you).



### Parent/Guardian Name (You)

Home Address (No PO Boxes)

City State Zip Code

Home Phone Work Phone

Cell Phone Email

2. Current Residence Information

a. How many people live in your residence? 

# 1

You # of O ther Adults

( older than 18) # of Children

(younger than 17 )



### b. How long have you lived at your current address?

# of years # of months



### c. What is your monthly rent or mortgage?



#  Rent $ 

#  Mortgage $ 

#  Other

d. Who pays your monthly rent or mortgage? (check all that apply)



#  Myself (OSP Parent/Guardian) 

#  Non

- government organization



#  DCHA/HCVP/HUD 

#  Friend or relative (does not reside with you)



#  Spouse or other adult (living with you) 

#  Other:

______________________________



### e. Check if any of the following apply:



#  Live with friend or relative (other than minor c hildren) 

#  Live with roommate or housemate

### Household Number : « HH »

Scholarship Application – ( SY 2012 -13 )

– Parts A and B

D.C. Opportunity Scholarship Program Page 4 of 9 

### 3. Student Information

Complete section below for all students applying for the OSP.

Student 1 Student 2 Student 3

Name of Student

______________________ ______________________ ______________________

Social Security Number

______ -

_____ -

______ ______ -

_____ -

______ ______ -

_____ -

______

Date of Birth ______/______/______ ______/______/______ ______/______/______

Gender 

###  Male 

###  Female 

###  Male 

###  Female 

###  Male 

###  Female

Relationship to You 

###  Son/Daughter



###  Foster Child



###  Grandchild



###  Niece/Nephew



###  Other: ____________ 

###  Son/Daughter



###  Foster Child



###  Grandchild



###  Niece/Nephew



###  Other:

____________ 

###  Son/Daughter



###  Foster Child



###  Grandchild



###  Niece/Nephew



###  Other: ____________

Is the student

Hispanic/Latino (a)? 

###  Yes 

###  No 

###  Yes 

###  No 

###  Yes 

###  No

What is the student’s

race?

Check one or more. 

###  White



###  Black, African

- American



###  American Indian or

Alaskan Native



###  Asian



###  Native Ha waiian or Other

Pacific Islander 

###  White



###  Black, African

- American



###  American Indian or

Alaskan Native



###  Asian



###  Native Ha waiian or Other

Pacific Islander 

###  White



###  Black, African

- American



###  American Indian or

Alaskan Native



###  Asian



###  Native Ha waiian or Other

Pacific Islander

Current Grade

________ ________ ________

Current School Name

______________________ ______________________ ______________________

Current School Type 

###  Neighborhood (assigned)

public school



###  Charter school (public)



###  Other public school of

choice



###  Private school



###  Private school (DCPS)



###  Home school



###  Daycare/Not in school



###  Don’t know 

###  Neighborhood (assigned)

public school



###  Charter school (public)



###  Other public school of

choice



###  Private school



###  Private school (DCPS)



###  Home school



###  Daycare/Not in school



###  Don’t know 

###  Neighborhood (assigned)

public school



###  Charter school (public)



###  Other public school of

choice



###  Private school



###  Private school (DCPS)



###  Home school



###  Daycare/Not in school



###  Don’t know

Does the student have

any of the following

challenges?

Will not affect their

chances of receiving a

scholarship. 

###  N ot applicable (N/A)



###  Physical disability



###  Learning disability



###  Problems understanding

English



###  Individualized Education

Plan (IEP) 

###  Not applicable (N/A)



###  Physical disability



###  Learning disability



###  Problems understanding

English



###  Individualized Education

Plan (IEP) 

###  Not applicable (N/A)



###  Physical disability



###  Learning disability



###  Problems understanding

English



###  Individualized Education

Plan (IEP)

### Household Number: « HH »

Scholarship Application – ( SY 2012 -13 )

– Parts A and B

D.C. Opportunity Scholarship Program Page 5 of 9 

### 3. Student Information (continued)

Complete section below for any additional students applying to the OSP.

Student 4 Student 5 Student 6

Name of Student

______________________ ______________________ ______________________

Social Security Number

______ -

_____ -

______ ______ -

_____ -

______ ______ -

_____ -

______

Date of Birth ______/______/______ ______/______/______ ______/______/______

Gender 

###  Male 

###  Female 

###  Male 

###  Female 

###  Male 

###  Female

Relationship to You 

###  Son/Daughter



###  Foster Child



###  Grandchild



###  Niece/Nephew



###  Other: ____________ 

###  Son/Daughter



###  Foster Child



###  Grandchild



###  Niece/Nephew



###  Other: ____________ 

###  Son/Daughter



###  Foster Child



###  Grandchild



###  Niece/Nephew



###  Other: ____________

Is the student

Hispanic/Latino (a)? 

###  Yes 

###  No 

###  Yes 

###  No 

###  Yes 

###  No

What is the student’s

race?

Check one or more. 

###  White



###  Black, African

- American



###  American Indian or

Alaskan Native



###  Asian



###  Native Ha waiian or Other

Pacific Islander 

###  White



###  Black, African

- American



###  American Indian or

Alaskan Native



###  Asian



###  Native Ha waiian or Other

Pacific Islander 

###  White



###  Black, African

- American



###  American Indian or

Alaskan Native



###  Asian



###  Native Ha waiian or Other

Pacific Islander

Current Grade

________ ________ ________

Current School Name

______________________ ______________________ ______________________

Current School Type 

###  Neighborhood (assigned)

public school



###  Charter school (public)



###  Other public school of

choice



###  Private school



###  Private school (DCPS)



###  Home school



###  Daycare/Not in school



###  Don’t know 

###  Neighborhood (assigned)

public school



###  Charter school (public)



###  Other public school of

choice



###  Private school



###  Private school (DCPS)



###  Home school



###  Daycare/Not in school



###  Don’t know 

###  Neighborhood (assigned)

public school



###  Charter school (public)



###  Other public school of

choice



###  P rivate school



###  Private school (DCPS)



###  Home school



###  Daycare/Not in school



###  Don’t know

Does the student have

any of the following

challenges?

Will not affect their

chances of receiving a

scholarship. 

###  Not applicable (N/A)



###  Physical disability



###  Learning disability



###  Problems understanding

English



###  Individualized Education

Plan (IEP) 

###  Not applicable (N/A)



###  Physical disability



###  Learning disability



###  Problems understanding

English



###  Individualized Educati on

Plan (IEP) 

###  Not applicable (N/A)



###  Physical disability



###  Learning disability



###  Problems understanding

English



###  Individualized Education

Plan (IEP)

### Household Number : « HH »

Scholarship Application – ( SY 2012 -13 )

– Parts A and B

D.C. Opportunity Scholarship Program Page 6 of 9 

### 4. Complete the following statement

List all childre n – scholarship applicants and non

- applicants

– in your household for whom you are the guardian



### I certify that I, am the current guardian of the child(ren) listed below:

OSP Parent/Guardian Name



### Child Name (s) (17 and Younger) DOB (mm/dd/yyyy) Foster Child/Ward of DC

(Check box if applicable)



## / / 

# 

/ / 

# 

/ / 

# 

/ / 

# 

/ / 

# 

/ / 

# 

5. Why are you applying to the D.C. Opportunity Scholarship Program?



# CONTINUE TO NEXT PAGE 

# 

### Household Number: « HH »

Scholarship Application – ( SY 2012 -13 )

– Parts A and B

D.C. Opportunity Scholarship Program Page 7 of 9 

### 6

. Information for Parent/Guardian and Additional Adult(s)

Your financial household includes people who financially contribute to your household expenses and/or vice versa.

Fill the table below for all adults (18+) in your financial household.

You Adult 2 Adult 3

Name of Adult

_____________________________ _____________________________ _____________________________

Social Security Number

______ -

_____ -

______ ______ -

_____ -

______ ______ -

_____ -

______

D ate of Birth (mm/dd/yy) ____/____/____ ____/____/____ ____/____/____

Gender 

###  Male 

###  Female 

###  Male 

###  Female 

###  Male 

###  Female

Is the adult

Hispanic/Latino(a)? 

###  Yes 

###  No 

###  Yes 

###  No 

###  Yes 

###  No

What is the adult’s race?

Check one or more. 

###  White



###  Black, African

- American



###  American Indian or

Alaskan Native



###  Asian



###  Native Ha waiian or Other

Pacific Islander 

###  White



###  Black, African

- American



###  American Indian or

Alaskan Native



###  Asian



###  Native Ha waiian or Other

Pacific Islander 

###  White



###  Black, African

- American



###  American Indian or

Alaskan Native



###  Asian



###  Native Ha waiian or Other

Pacific Islander

What is the adult’s highest

level of education? 

###  Less than high school

diploma



###  GED



###  High school diploma



###  Some college or training,

no degree



###  AA/AS or Certificate from

training program



###  Bachelor’s degree



###  Master’s degree or

higher



###  Don’t know 

###  Less than high school

diploma



###  GED



###  High school diploma



###  Some college or training,

no degree



###  AA/AS or Certificate from

training program



###  Bachelor’s degree



###  Master’s degree or

higher



###  Don’t know 

###  Less than high school

diploma



###  GED



###  High school diploma



###  S ome college or training,

no degree



###  AA/AS or Certificate from

training program



###  Bachelor’s degree



###  Master’s degree or

higher



###  Don’t know

Since beginning work as an

adult, about how many

years and months has the

adult worked? _____ ______ years, and

___________ months _____ ______ years, and

___________ months _____ ______ years, and

___________ months

Does the adult currently

have a job? 

###  Yes, full

- time job (35 hr+)



###  Yes, part

- time job



###  Not currently working 

###  Yes, full

- time job (35 hr+)



###  Yes, part

- time job



###  Not currently working 

###  Yes, full

- time job (35 hr+)



###  Yes, part

- time job



###  Not currently working

### Household Number: « HH »

Scholarship Application – ( SY 2012 -13 )

– Parts A and B

D.C. Opportunity Scholarship Program Page 8 of 9 

### 6. Information for Parent/Guardian and Additional Adult(s) (Continued)

Your financial household includes people who financially contribute to your household expenses and/or vice versa.

Fill the table below for all adults (18+) in your financial household that are listed on the previous page.

You Adult 2 Adult 3

Name of Adult

(from previous page)

_____________________________ _____________________________ _____________________________

Relationship to you 

### Self  Spouse



###  Parent/Step

- Parent



###  Boyfriend/Girlfriend



###  Son/Daughter (18+)



###  Grandparent



###  Other:

______________ 

###  Spouse



###  Parent/Step

- Parent



###  Boyfriend/Girlfriend



###  Son/Daughter (18+)



###  Grandparent



###  Other:

______________

Marital Status

& Date (mm/yy) 

###  Single, never married



###  Married, Date: ______



###  Widow ed, Date: ______



###  Divorc ed, Date: ______



###  Separat ed, Date: ______ 

###  Single, never married



###  Married, Date: ______



###  Widow ed, Date: ______



###  Divorc ed, Date: ______



###  Separat ed, Date: ______ 

###  Single, never married



###  Married, Date: ______



###  Widow ed, Date: ______



###  Divorc ed, Date: ______



###  Separat ed, Date: ______



### 7. In the past 12 months, did any members of your household listed on this application receive SNAP

(formerly Food Stamps) and/or public assistance payments, welfare benefits (ex. TANF/GC)?



##  Yes 

#  D o not fill out chart below

. C omplete ESA Statement Release Form

.



##  No 

#  Fill out income chart below for all adults

.



##  Not Sure 

#  Fill out i ncome chart below for all adults and complete ESA Statement Release Form

.



### Income Sources (2011) You Adult 2 Adult 3

No i ncome received 

#   

Filed (or will file) federal tax return 

#   

WILL NOT file tax return : total

wages, salaries, tips earned 

## $

_____________ _ _____ 

## $

_____________ _ _____ 

## $

_____________ _ _____

Social Security Income, pensions,

retirement , v eterans’ benefits 

#   

Disability benefits (include SSI for

dependent s) 

#   

Child support or alimony payments 

#   

Monetary g ifts from f amily/friends 

#   

Other income:

________________ 

#   

To determine eligibility, y ou are required to provide official documentation with 2011 annual amounts

.

### Household Number : « HH »

Scholarship Application – ( SY 2012 -13 )

– Parts A and B

D.C. Opportunity Scholarship Program Page 9 of 9 

### 8

. Alternate Contacts

Do not list yourself as a contact. Common examples of contacts are relatives and neighbors.

Contact Person 1 Name

Relationship to You Home Phone

Work Phone Cell Phone

Contact Person 2 Name

Relationship to You Home Phone

Work Phone Cell Phone

Student Contact Name

Cell Phone Email



# CONTINUE TO NEXT PAGE 

# 

### Household Number: « HH »

Scholarship Application – ( SY 2012 -13 )

– Part C

D.C. Opportunity Scholarship Program Page 1 of 3 

# Part C: Current School Information

**Instructions**

• This section must be completed for each student listed on the first page of your scholarship application.

• A separate questionnaire must be filled out on behalf of each student applying for the scholarship.

• Do not leave any questions blank

.

Name of Student

1. Is this student currently in daycare or not yet enrolled in school?



#  Yes 

#  Go to question 5. 

#  No 

#  Go to question 2.



### 2. What overall grade would you give this child’s current school?

Che ck one box below.



#  Excellent (A)



#  Good (B)



#  Fair (C)



#  Unsatisfactory (D)



#  Failing (F)



### 3

. How satisfied are you with the following aspects of this child’s current school?

Very Dissatisfied Dissatisfied Satisfied Very Satisfied

a. Location of school

.................................................... 

#    

b. School safety

............................................................ 

#    

c. Class sizes

................................................................ 

#    

d. School facilities

........................................................ 

#    

e. Respect between teachers and students

................ 

#    

f. How much teachers inform parents of students’

progress

................................ ................................ ... 

#    

g. How much students can observe religious traditions 

#    

h. Parental involvement in school

............................... 

#    

i. Discipline

................................................................ . 

#    

j. Academic quality

..................................................... 

#    

k. Racial mix of students

.............................................. 

#    

l. Services for students with special needs

.................  Check here if not applicable 

#    

### Household Number: « HH »

Scholarship Application – ( SY 2012 -13 )

– Part C

D.C. Opportunity Scholarship Program Page 2 of 3 

### 4

. Approximately how much homework is assigned to this child on an average day?

Che ck one box below.



#  0

- 30 min utes 

#  11⁄2 to 2 hours



#  30 minutes to 1 hour 

#  2 to 21⁄2 hours



#  1 to 11⁄2 hours 

#  More than 21⁄2 hours



#  11⁄2 to 2 hours 

#  Don’t know



### 5

. In the past MONTH, how often did you do the following?

Check only one box for each question below.

Never Once 2 or 3 Times 4 or 5 Times 6 or More Times

a. Help this child with his or her homework

......... 

#     

b. Help this child with reading or math that

was not part of his or her homework

................ 

#     

c. Talk with this child about his or her

experiences in school

................................ ........ 

#     

d. Attended school activities

................................ . 

#     

e. Worked with child on school project

................ 

#     

6

. What will be the most important considerations in your choice of schools?

Read the list of considerations, then rank your top 3 priorities when choosing a school by writing the corresponding

letter in the section below. Choose only three priorities.

List of Considerations When Choosing a School

a. Location of school g. Parental involvement in the schools

b. School safety h. Discipline

c. Class sizes i. Academic quality

d. School facilities j. Racial mix of students

e. Respect between students and teachers k. Services for students with special needs

f. How much teachers inform parents of students’ progress l. How much students can observe religious traditions



### Most Important Considerations

1. First Priority

2. Second Priority

3. Third Priority

### Household Number: « HH »

Scholarship Application – ( SY 2012 -13 )

– Part C

D.C. Opportunity Scholarship Program Page 3 of 3 

### 7

. Do you know which school(s) you would like your child to apply to for Fall 2011?

If this child is awarded a scholarship, you will also need to apply to a participating private school in order to use their

scholarship.



#  No



#  Yes (Please list the schools below in order of your first, second, and third preference.)

a. First choice school

b. Second choice school

c. Third choice school



### 8. Certification

I certify that all information on this form 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 the

Trust will have access to my child’s report cards while my chil d is participating in the program and that this

information will be held strictly confidential. I understand that deliberate misrepresentation of the

information or documentation will result in the scholarship being denied or revoked, and may subject me

t o prosecution under District and Federal laws.

Signature Parent/Guardian Name (Print) Date