Att 2 Consent Form

U.S. Department of Education

Impact Evaluation of the DC Opportunity Scholarship Program

Office of Management and Budget

Statement for Paperwork Reduction Act Submission

Attachment 2

Contract ED-04-CO-0126

September 12, 2008

Attachment 2

DC Opportunity Scholarship Program

Application and Consent Form

O MB: 1855-0015

Expiration Date: 11/30/04

D.C. Opportunity Scholarship Program Application

and Evaluation Questionnaire
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. This form is in two sections.

Section 1: Scholarship Application and Contact Information

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

Part B: Scholarship Eligibility Form. Household composition and other information

needed to determine eligibility for the D.C. Opportunity Scholarship Program.

Part C: Additional contact information so that we can find you in case you move or

change your phone number.

Section 2: Evaluation Questionnaire

These questions will not affect your chances of getting a scholarship, and individual family answers will not be seen by anyone outside the evaluation team. The answers will be combined so that Congress and policy makers can use the information to see how well the children in the program are doing. These questions need to be answered by all applicants.

Part D: General questions about the adults in your household.

Part E: General questions about the children in your household.

Applying Parent/Guardian (please put this name on the top of each page of the application):

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 (expires). The time required to complete this information collection is estimated at 25 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

In early 2004, the U.S. Congress passed the DC School Choice Incentive Act. This law established a new, five-year school choice program for low-income residents of Washington, DC. The Program will provide scholarships to enable low-income elementary and secondary education students to attend private schools in addition to the public schools already available to them.

• Scholarships are for up to $7,500 per year for tuition fees (for example books, uniforms, and transportation expenses). Under the current law, Congress has authorized the Program to run until the end of the school year 2009-2010.

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

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

• Once a child receives a scholarship, they will receive one every year the program is funded, as long as they remain eligible and maintain good academic standing in a participating school.

• If there are more applicants than slots in schools or available funds, the law requires that scholarships will be given out through a lottery. Scholarships will be considered conditional until the student is actually placed in a school. Children who do not receive a scholarship this year and are eligible may receive a scholarship next year.

• 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 one of Washington Scholarship Fund’s (WSF) partners once they have had time to review your submission in detail.

• Scholarships are awarded to individual students, not to families. Scholarships can not be transferred.

• Once a student has a conditional 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.

• WSF encourages conditional scholarship recipients to apply to as many schools as possible. In case your child does not get his/her first-choice school, it is important to have other choices

• Schools that you apply to will inform you whether or not each applicant is admitted.

• 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 202-293-5560 or at 1-888-DC-YOUTH

  • If you have any questions about the evaluation requirements, please call Juanita Lucas-McLean at

Westat at 301-294-2866.

• No school charged any families tuition, even when tuition was well over the $7,500 scholarship amount.

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 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 be a resident of the District of Columbia and my annual household income must be below certain specified amounts. (Questions in Part B on the next page will be used to determine your initial eligibility.)

• 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.

• If my child is not selected to receive a scholarship this year, he or she may be included in a lottery drawing for the following year, as long as the family remains eligible under the Program’s rules.

• 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 and evaluation questionnaire, except as required by law.

Parent/Guardian Name….. ________________________________________

First name middle name last name

Parent/Guardian Signature… ___________________________________

Today’s Date……………… ___________________________________

Please list all children applying for a scholarship:

1. Child’s Name……………… ________________________________________________

First name middle name last name

2. Child’s Name……………… ________________________________________________

First name middle name last name

3. Child’s Name……………… ________________________________________________

First name middle name last name

4. Child’s Name……………… ________________________________________________

First name middle name last name

5. Child’s Name……………… ________________________________________________

First name middle name last name