Household Number : _

____________ OMB: 1855 - 001 5

D.C. Opportunity Scholarship Program Application Form – SY 201 X - 1 X Page **1** of **13**



# Scholarship Application D.C. Opportunity Scholarship Program

20 1 X - 1 X Thank you for your interest in the D.C. Opportunity Scholarship Program (OSP) . This form should be filled out by the parent or guardian who lives with the child(ren) applying for a scholarship. **Part A** Description of Opportunity Scholarship Program and signed agreement to participate **Part B** Informatio n needed to determine eligibility for D.C. Opportunit y Scholarship Program 

## 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

**Child #1** First Middle Last **Child #2** First Middle Last **Child #3** First Middle Last **Child #4** First Middle Last 

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

##  No 

##  Not sure

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 20 minutes per response, includi ng 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 required to obtain or retain benefi ts according to PL 108 199 Sec. 3 (Title III). Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Ave., SW, Wa shington, DC 20210-4537 or email ICDocketMgr@ed.gov and refere nce the OMB Control Number 1855 0015. Note: Please do not return the completed scholarship application to this address.Household Number : _

____________

D.C. Opportunity Scholarship Program Application Form – SY 201 X - 1 X Page **2** of **13** 

# Part A: Description of OSP & Agreement to Participate **1. Description	of	the	D.C.	Opportunity	Scholarship	Program	and	Evaluation**  The OSP provides scholarships to enable low - income D.C. elementary and secondary students to attend private schools. Receiving a scholarship will not interfe re in any way with any other public assistance your family may receive.

The amount of the scholarship will not be treated as income of the child or their parent/guardian for purposes of Federal tax laws or for determining eligibility for any other federal program.  Scholarships may only be used at a school participating in the D.C. Opportunity Scholarship Program. The Trust will provide you with a list of participating schools.  If there are more applicants than slots in schools or available funds, the law r equires that scholarships will be given out through a lottery. Th e lottery will give priority to eligible students who are attending an elementary school or secondary school identified for improvement, corrective action, or restructuring;  Only eligible families with **completed** applications will be included in the lottery. A completed application is one that includes: (1) the application form, (2) the necessary documentation proving eligibility, and (3) verification that your child participated in the pre - lottery reading and math tests that are required for the evaluation. If your application is determined to be incomplete ( missing any of those documents ) 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 DC Children and Youth Investment Trust Corporation ( Trust ) once we have had time to review your submission in detail.  If your child receives 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 your child is **admissible** . We will ask you to list your top 3 choices of schools. We will make every effort to place each child in his or her first choice school. But i f 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, and no payment can be made with their scholarship, until the Trust places them.  Whi le 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 measure the success of the Program has been. As part of the Eva luation, applicants must agree to: o Annual testing of your child in reading and m ath , and surveys of children in grades 4 and above ; o Parent surveys o 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 DC Children and Youth Investment Trust Corporation (Trust) at 1 - 888 - DC -YOUTH. 

## 2. **Agreement	to	Participate** When the U.S. Congress created the D.C. Opportu nity Scholarship Program, it established rules for who is eligible to apply and how those applications should be handled. Congress also required that an evaluation beHousehold Number : _

____________

D.C. Opportunity Scholarship Program Application Form – SY 201 X - 1 X Page **3** of **13** conducted to study the Program and students’ experiences before, during, and after bein g 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. Opportun ity 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 2011 - 12 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 Program.  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 surve ys, 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(re n) 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 i dentifiable information in this application, except as required by law. Signature Parent/Guardian Name (Print) Date



# Part B: Program Application **3. 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 

##  Newspaper Article, Ad, or Metro 

##  School 

##  Website 

##  Community Organization 

##  Trust Representative 

##  Radio 

##  Other 

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

##  English 

##  Spanish 

##  Amharic 

##  Hindi/Urdu 

##  Vietnamese 

##  OtherHousehold Number : _

____________

D.C. Opportunity Scholarship Program Application Form – SY 201 X - 1 X Page **4** of **13** 

## Instructions  Fill out all pages of this form – **do not leave any questions blank**  Submit additional documents in person at Trust offic e, fax (202.478.0991), or email ospadmin@cyitc.org  You will receive a letter in the mail with the status of your application  Please a llow 5 - 10 business days for processing 

## 1. **Re sidency and Contact Information**  Fill in contact information for applying parent/g uardian (you). Parent/Guardian Name (You) Physical Address (No PO Boxes) City State Zip Code Home Phone Work Phone Cell Phone Email



## 3. **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 

## 2. **How long have you lived at your current address**  **?** # of Years # of Months



## 4. **How many people live in your residence?** You Other Adults ( 18+ ) ChildrenHousehold Number : _

____________

D.C. Opportunity Scholarship Program Application Form – SY 201 X - 1 X Page **5** of **13** 

## 6. **In the past 12 months, d id your family receive any**  **DC government assistance?**  If you answer yes, please fill out the IMA Statement Release Form . Public assistance payments, welfare benefits (ex. TANF, G C ) 

##  Yes 

##  No Supplemental Nutrition Assistance Program/SNAP (formerly Food Stamps) 

##  Yes 

##  No Medical Assistance ( i.e. Medicaid) 

##  Yes 

##  No 

## 7. **C omplete the following statemen**  **t** I certify that I, ( Parent/Guardian Name ), am the current guardian of the child(ren) listed below: Ch ild (ren) Name (s) – 17 and Younger List all children (whether or not you are applying for them) DOB (mm/dd/yyyy) Foster Child/Ward of DC (check box) 

## / / 

#  / / 

#  / / 

#  / / 

#  / / 

#  **1 5.**  **What is your monthly rent or mortgage?** 

#  Rent 

## $ 

#  Mortgage 

## $ 

#  Other a. Who pays your monthly rent or mortgage ? (check all that apply) 

##  Myself (OSP Parent/Guardian) 

##  Non - government o rganization 

##  DCHA/HCVP/HUD 

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

##  Spouse or other adult (living with you) 

##  Other: __________________________________ b. Check if any of the following apply: 

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

##  Live with roommate or housemate



## 8. **Information for Parent** **/Guardian and Additional Adult**  **(s)** Your financial household includes people who financially contribute to your household expenses and/orHousehold Number : _

____________

D.C. Opportunity Scholarship Program Application Form – SY 201 X - 1 X Page **6** of **13** 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

**______ -** **_____ -** **______ ______** **- _____** **- ______**  **______ -** **_____ -** **______** Date of Birth (m/d/yy)

___ __ _/___

__ _/___

___ ___

__ _/___

__ _/___

___ ___

__ _/___

__ _/___

___ Gender 

###  Male 

###  Female 

###  Male 

###  Female 

###  Male 

###  Female 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:

______________ What is the adult’s race? 

###  White 

###  Black, African - American 

###  American Indian or Alaskan Native 

###  Asian 

###  Native Hawaiian or Other Pacific Islander 

###  White



###  Black, African - American 

###  American Indian or Alaskan Native 

###  Asian 

###  Native Hawaiian or Other Pacific Islander 

###  White



###  Black, African - American 

###  American Indian or Alaskan Native 

###  Asian 

###  Native Hawaiian or Other Pacific Islander Is the adult Hispanic/Latino(a)? 

###  Yes 

###  No 

###  Yes 

###  No 

###  Yes 

###  No
Marital status 

###  Single, never married 

###  Married, Date: ______ 

###  Widowed, Date: ______ 

###  Divorced, Date: ______ 

###  Separated, Date: ______ 

###  Single, never married 

###  Married, Date: ______ 

###  Widowed, Date: ______ 

###  Divorced, Date: ______ 

###  Separated, Date: ______ 

###  Single, never married 

###  Married, Date: ______ 

###  Widowed, Date: ______ 

###  Divorced, Date: ______ 

###  Separated, Date: ______ 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 workingHousehold Number : _

____________

D.C. Opportunity Scholarship Program Application Form – SY 201 X - 1 X Page **7** of **13** 

## 8. **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. **You Adult 2**  **Adult 3** Name of Adult Since beg i n ning work as an adult, about how many years and months ha s the adult worked? _____ ______ years, and

___________ months _____ ______ years, and

___________ months _____ ______ years, and

___________ months

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 

###  Some college or training, no degree 

###  AA/AS or Certificate from training program 

###  Bache lor’s degree 

###  Master’s degree or higher 

###  Don’t know 

## 9. **Financial 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. 

### Income Sources (2010) **You Adult 2**  **Adult 3** No Income received 

##    Filed federal tax return 

##    If you DID NOT file tax return : total wages, salaries, tips 

# $   Social Security Income, pensions, retirement, v eterans’ benefits 

##    Disability benefits (include SSI for dependent s) 

##    Public assistance payments , welfare benefits ( ex. TANF, GC) 

##    Child support or alimony payments 

##    Gifts from family/friends 

##   Household Number : _

____________

D.C. Opportunity Scholarship Program Application Form – SY 201 X - 1 X Page **8** of **13**

**You are required to provide official documentation with 2010 annual amounts** Other income:

________________ 

##    **10. 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 (m/d/yy)

___ __ _/___

__ _/___

___ ___

__ _/___

__ _/___

___ ___

__ _/___

__ _/___

___ 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: _____________

What is the student’s race? 

###  White 

###  Black, African -American 

###  American Indian or Alaskan Native 

###  Asian 

###  Native Hawaiian or Other Pacific Islander 

###  White



###  Black, African - American 

###  American Indian or Alaskan Native 

###  Asian 

###  Native Hawaiian or Other Pacific Islander 

###  White



###  Black, African - American 

###  American Indian or Alaskan Native 

###  Asian 

###  Native Hawaiian or Other Pacific Islander Is the student Hispanic/Latino (a)? 

###  Yes 

###  No 

###  Yes 

###  No 

###  Yes 

###  No Does the student have any of the following challenges? (Will not affect their chances of receiving a scholarship.) 

###  N/A 

###  Physical disability 

###  Learning disability 

###  Problems understanding English 

###  N/A



###  Physical disability 

###  Learning disability 

###  Problems understanding English 

###  N/A



###  Physical disability 

###  Learning disability 

###  Problems understanding English Grade in Current School (2010 - 11) Current School Name (2010 - 11)Household Number : _

____________

D.C. Opportunity Scholarship Program Application Form – SY 201 X - 1 X Page **9** of **13** Current School Type (2010 - 11) 

###  Neighborhood (assigned) public school 

###  Charter school (public)Other public school (e.g., magnet schools) 

###  Private school 

###   Neighborhood (assigned) public school 

###  Charter school (public)Other public school (e.g., magnet schools) 

###  Private school 

###   Neighborhood (assigned) public school 

###  Charter school (public)Other public school (e.g., magnet schools) 

###  Private school 

###  

## 10. **Student Information**  **(Continued)** Complete section below for all students applying for the OSP. **Student 1 Student 2**  **Student 3** Name of Student Does the student have any of the following challenges? (Will not affect their chances of receiving a scholarship.) 

###  N/A 

###  Physical disability 

###  Learning disability 

###  Problems understanding English 

###  Individualized Education Plan (IEP) 

###  N/A



###  Physical disability 

###  Learning disability 

###  Problems understanding English 

###  Individualized Education Plan (IEP) 

###  N/A



###  Physical disability 

###  Learning disability 

###  Problems understanding English 

###  Individualized Education Plan (IEP) **If your child is awarded a scholarship** , do you know which school(s) you would like to apply for Fall ’11? 

###  No 

###  Yes (list school names)

___________________

___________________

___________________ 

###  No



###  Yes (list school names)

___________________

___________________

___________________ 

###  No



###  Yes (list school names)

___________________

___________________

___________________ Why are you applying to the D.C. Opportunity Scholarship Program ?Household Number : _

____________

D.C. Opportunity Scholarship Program Application Form – SY 201 X - 1 X Page **10** of **13** Using the list of children in your answer to Section 10 , please fill out 11 - 15 out for each child listed. A separate must be filled out on behalf of each child who is applying for the scholarship. 11 . How satisfied are you with the following aspects of ________ (CHILD’S NAME) 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 the school ..........     i. Discipline ................................ ...................     j. Academic quality ................................ .......     k. Racial mix of students ...............................     l. Services for students with special needs ..    Household Number : _

____________

D.C. Opportunity Scholarship Program Application Form – SY 201 X - 1 X Page **11** of **13** 12 . What overall grade would you give this child’s current school? (Check one box.) a. Excellent (A) ................................ ................................ ...................  b. Good (B) ................................ ................................ .........................  c. Fair (C) ................................ ................................ ............................  d. Unsatisfactory (D) ................................ ................................ ..........  e. Failing (F) ................................ ................................ ........................  13 . What will be the most important considerations in your choice of schools? Select up to three items and mark your top priority in column 1, your second priority in column 2, and your third priority in column 3. First Priority (Column 1) (mark only one) Second Priority

(Column 2) (mark only one) Third Priority

(Column 3) (mark only one) a. Location of school ................................ ......    b. School safety ................................ ..............    c. Class sizes ................................ ...................    d. School facilities ................................ ..........    e. Respect between students and teachers ..    f. How much teachers inform parents of students’ progress ................................ .....    g. How much students can observe religious traditions ................................ ....................    h. Parental involvement in the schools .........    i. Discipline ................................ ....................    j. Academic quality ................................ .......    k. Racial mix of students ................................    l. Services for students with special needs ...   Household Number : _

____________

D.C. Opportunity Scholarship Program Application Form – SY 201 X - 1 X Page **12** of **13** 14 . Approximately how much homework is assigned to this child on an average day? (Check one box.) a. 0 - 30 min. ................................ ................................ ......................  b. 30 min. - 1 hour ................................ ................................ ..............  c. 1 - 11⁄2 hours ................................ ................................ ...................  d. 11⁄2 - 2 hours ................................ ................................ ...................  e. 2 - 21⁄2 hours ................................ ................................ ..................  f. More than 21⁄2 hours ................................ ................................ ......  g. Don’t know ................................ ................................ ....................  15 . In the past MONTH, how often did you do the following?

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 ........      16. If you _________ (CHILD’S NAME) is awarded a scholarship, do you know which school(s) you would like the child to apply to for Fall 2011? Please list them in the order of your preference. a. First choice school. ................................ ................................ b. Second choice school. ................................ ........................... c. Third choice school. ................................ ...............................Household Number : _

____________

D.C. Opportunity Scholarship Program Application Form – SY 201 X - 1 X Page **13** of **13** 17. Why are you applying to the DC Opportunity Scholarship Program for this child?



## 11. **Certification Signature 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 child 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 to prosecution under District and Federal laws.** 
Signature Parent/Guardian Name (Print) Date