Scholarship Application D.C. Opportunity Scholarship Pro

Household Number: _____________

OMB: 1855-0015 expires 5/30/201X

S cholarship Application

D.C. Opportunity Scholarship Program

2011-2012

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 Signed agreement to participate

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 child attached)

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
Child #5
		First		Middle		Last
Child #6
		First		Middle		Last

Have you ever applied before to the OSP for any of your child(ren)?
	Yes		No		Not sure

NOTICE: 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 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 required to obtain or retain a benefit 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.

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 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

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

What language is spoken most often in your home?
	English		Spanish
	Amharic		Hindi/Urdu
	Vietnamese		Other

Part B: Program Application

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

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

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

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

How many people live in your residence?	You		Other Adults (18+)		Children
	1

What is your monthly rent or mortgage?



Rent

$



Mortgage

$



Other

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: __________________________________

Check if any of the following apply:



Live with friend or relative (other than minor children)



Live with roommate or housemate

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)
		/ /		
		/ /		
		/ /		
		/ /		
		/ /		

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	______-_____-______	______-_____-______	______-_____-______
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: ______________
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 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
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

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
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						
Other income: ________________						
You are required to provide official documentation with 2010 annual amounts.

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: _____________
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 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
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)

Student Information (Continued) Complete section below for all students applying for the OSP.
	Student 4	Student 5	Student 6
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: _____________
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 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
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)

Part C: Current School Information

Instructions

• Using the list of children in your answer on page 1, please fill out 11-15 out for each child listed.

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

• Do not leave any questions blank.

Current School Information for Student
Name of Student
Current School Name (2010-11)				Current Grade
Current School Type (2010-11):			Neighborhood (assigned) public school Charter school (public) Other public school (e.g., magnet schools) Private school Private school (DCPS) Not in school/daycare Don’t know

How satisfied are you with the following aspects of this child’s current school?
	Very Dissatisfied	Dissatisfied	Satisfied	Very Satisfied
Location of school				
School safety				
Class sizes				
School facilities				
Respect between teachers and students				
How much teachers inform parents of students’ progress				
How much students can observe religious traditions				
Parental involvement in the school				
Discipline				
Academic quality				
Racial mix of students				
Services for students with special needs				

What overall grade would you give this child’s current school? Check one box.
Excellent (A)	
Good (B)	
Fair (C)	
Unsatisfactory (D)	
Failing (F)	

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)
Location of school			
School safety			
Class sizes			
School facilities			
Respect between students and teachers			
How much teachers inform parents of students’ progress			
How much students can observe religious traditions			
Parental involvement in the schools			
Discipline			
Academic quality			
Racial mix of students			
Services for students with special needs			

Approximately how much homework is assigned to this child on an average day? Check one box.
0 - 30 min.	
30 min.- 1 hour	
1 - 1½ hours	
1½ - 2 hours	
1½ - 2 hours	
2 - 2½ hours	
More than 2½ hours	
Don’t know	

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
Help this child with his or her homework					
Help this child with reading or math that was not part of his or her homework					
Talk with this child about his or her experiences in school					
Attended school activities					
Worked with child on school project					

If this child 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.
	No
	Yes (answer questions below)
First choice school
Second choice school
Third choice school

8. Why are you applying to the DC Opportunity Scholarship Program for this child?

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

D.C. Opportunity Scholarship Program Application Form – SY 2011-12 Page 1 of 13