Household Number: _____________

OMB: 1855-0015

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

Scholarship Application

D.C. Opportunity Scholarship Program

201X-1X

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 Information needed to determine eligibility for D.C. Opportunity 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, 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 required to obtain or 

retain benefits 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, 

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.
Household Number: _____________

D.C. Opportunity Scholarship Program Application Form – SY 201X-1X 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 interfere 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 requires that scholarships will be 

given out through a lottery. The 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 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, and no payment can be 

made with their scholarship, until the Trust 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 measure the success of the 

Program has been. As part of the Evaluation, applicants must agree to:

o Annual testing of your child in reading and math, 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. 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 
Household Number: _____________

D.C. Opportunity Scholarship Program Application Form – SY 201X-1X Page 3 of 13

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 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 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 Department 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

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  Other
Household Number: _____________

D.C. Opportunity Scholarship Program Application Form – SY 201X-1X 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 office, fax (202.478.0991), or email ospadmin@cyitc.org

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

 Please allow 5-10 business days for processing 

1. Residency and Contact Information

Fill in contact information for applying parent/guardian (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+)

Children
Household Number: _____________

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

6. In the past 12 months, did 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, GC)  Yes  No

Supplemental Nutrition Assistance Program/SNAP 

(formerly Food Stamps)  Yes  No

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

7. Complete the following statement

I certify that I, (Parent/Guardian Name), 

am the current guardian of the child(ren) listed below: 

Child(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 organization

 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/or 
Household Number: _____________

D.C. Opportunity Scholarship Program Application Form – SY 201X-1X 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 working
Household Number: _____________

D.C. Opportunity Scholarship Program Application Form – SY 201X-1X 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 beginning work as 

an adult, about how 

many years and months 

has 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

 Bachelor’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, veterans’ benefits   

Disability benefits (include SSI for 

dependents)   

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 201X-1X 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 201X-1X 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 201X-1X 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 201X-1X 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 201X-1X 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 201X-1X 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