DC School Choice Application

		Household Number

OMB: 1855-0015

D.C. Opportunity Scholarship Program Application

School Year 2008-2009
Your Child’s Future, Your Peace of Mind

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

Scholarship Application and Contact Information

Part A: A description of the Program and your signed agreement to participate.

Part B: Asks about the number of people in your household and other information needed to determine eligibility for the D.C. Opportunity Scholarship Program.

Part C: Contact information for friends and family so that we can find you and/or your child/ren in case you move or change your phone number.

Applying Parent/Guardian:

Parent/Guardian Name _________________________________________________________

Street Address _______________________________________________________________

City _____________________________ State ________ Zip Code ______________

Home Phone Number (_______) ___________________ Work Phone: (_____) _________

Mobile Phone (_____) ____________________ E-Mail: _______________________

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

Part A. Description of the Program and Agreement to Participate

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

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

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

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

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

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

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

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

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

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

• Annual testing of your child

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

• Surveys of children in grades 4 and above

• Collection of files and records from your child’s school

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

2. Agreement to Participate

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

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

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

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

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

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

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

Parent/Guardian Name(print) _______________________________________

First name Middle name Last name

Parent/Guardian Signature ___________________________________

Today’s Date ___________________________________

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

for the OSP before?

1. Child’s Name ________________________________________________  Yes  No

First name Middle name Last name

2. Child’s Name ________________________________________________  Yes  No

First name Middle name Last name

3. Child’s Name ________________________________________________  Yes  No

First name Middle name Last name

4. Child’s Name ________________________________________________  Yes  No

First name Middle name Last name

5. Child’s Name ________________________________________________  Yes  No

First name Middle name Last name

6. Child’s Name ________________________________________________  Yes  No

First name Middle name Last name

Part B.

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

 Yes  No (Please see a WSF staff member)

B2a. How many people live in your house?

Number of Adults
Number of Children
Total

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

________ Number of children that applied for an Opportunity Scholarship

________ Number of children that received an Opportunity scholarship

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

 English

 Spanish

 Vietnamese

 Hindi

 Amharic

 Another language (please list) _________________________

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

(Check all that apply)

 Family member or friend

 Newspaper article

 Radio

 Applied last year

 Letter from WSF

 Other (please list) _________________________

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

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

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

B5. Continued

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

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

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

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

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

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

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

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

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

________ Number of adults that contribute to your expenses or that you support

________ Number of children that you support

________ Total

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

 Yes

 No

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

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

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

$ ______________________

GUIDELINE TABLE
Number in Household	Maximum Annual Income
1		18,889
2		25,327
3		31,765
4		38,203
5		44,641
6		51,079
7		57,517
8		63,955

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

 Yes (Go to B12)

 No (Go to B11)

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

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

B12. Do you rent or own your residence?

 Rent  Own  Live with friend/relative

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

 Amount paid by you or your household $_________ per month

 Amount paid by other source(s) $_________ per month

Other Source is:  Section 8 or housing voucher

 Relative

 Friend

 Other: __________________________

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

________ years and ________ months

Certification Signature

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

Parent/Guardian Name (Print)		Signature		Date

Part C. Additional Contact Information

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

Contact Information for:

Name: ______________________________________________________________________

Home Phone Number (_______) ___________________ Work Phone: (_____) _________

Mobile Phone (_____) ____________________ E-Mail: _______________________

Relationship to you (Parent/Guardian): ____________________________

Contact Information for:

Name: ______________________________________________________________________

Home Phone Number (_______) ___________________ Work Phone: (_____) _________

Mobile Phone (_____) ____________________ E-Mail: _______________________

Relationship to you (Parent/Guardian): ____________________________

Contact Information for:

Name: ______________________________________________________________________

Home Phone Number (_______) ___________________ Work Phone: (_____) _________

Mobile Phone (_____) ____________________ E-Mail: _______________________

Relationship to you (Parent/Guardian): ____________________________

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