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pdfOMB: 1855-0015
Household Number: «HH»
Scholarship Application
FOR TRUST USE ONLY
Date:
D.C. Opportunity Scholarship Program
Location:
2012-13
Initials:
Thank you for your interest in the D.C. Opportunity Scholarship Program (OSP). This application should be filled out by the
parent or guardian who lives with the child(ren) applying for a scholarship.
Part A
Part B
Part C
Agreement to Participate
Information needed to determine eligibility for D.C. Opportunity Scholarship Program
Current school information for each student applicant (form for one student attached)
E
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
PL
First
Middle
Last
Last
DOB (mm/dd/yy)
/
/
/
/
Child #3
/
/
Child #4
/
/
Child #5
/
/
Child #6
/
/
Child #1
SA
M
Child #2
2. 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 mandatory 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 202104537 or email [email protected] and reference the OMB Control Number 1855-0015. Note: Please do not return the completed
scholarship application to this address.
Scholarship Application – (SY 2012-13) – Parts A and B
D.C. Opportunity Scholarship Program
Page 1 of 9
Household Number: «HH»
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 2012-13 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.
SA
M
PL
E
•
Signature
Parent/Guardian Name (Print)
Date
1. How did you hear about the D.C. Opportunity Scholarship Program?
Check all that apply
Family Member or Friend
Letter/Flyer from the Trust
Newspaper Article, Ad, or Metro
Community Organization
Radio
Applied to OSP Before
School
OSP Website
Representative from the Trust
Other:
2. What language is spoken most often in your home?
English
Amharic
Vietnamese
Scholarship Application – (SY 2012-13) – Parts A and B
D.C. Opportunity Scholarship Program
Spanish
Hindi/Urdu
Other:
Page 2 of 9
Household Number: «HH»
Part B: Scholarship Application
Instructions
•
•
•
•
Fill out all pages of this form – do not leave any questions blank
Submit additional documents at Trust office, fax (202.478.0991), or email [email protected]
You will receive a letter in the mail with the status of your application
Please allow 10-15 business days for processing
1. Residency and Contact Information
Fill in contact information for applying parent/guardian (you).
Home Address (No PO Boxes)
State
Zip Code
PL
City
E
Parent/Guardian Name (You)
Home Phone
Work Phone
Cell Phone
Email
SA
M
2. Current Residence Information
a. How many people live in your residence?
1
You
# of Other Adults
(older than 18)
# of Children
(younger than 17)
b. How long have you lived at your current address?
# of years
# of months
c. What is your monthly rent or mortgage?
Rent $
Mortgage
$
Other
d. Who pays your monthly rent or mortgage? (check all that apply)
Myself (OSP Parent/Guardian)
DCHA/HCVP/HUD
Spouse or other adult (living with you)
Non-government organization
Friend or relative (does not reside with you)
Other: ______________________________
e. Check if any of the following apply:
Live with friend or relative (other than minor children)
Scholarship Application – (SY 2012-13) – Parts A and B
D.C. Opportunity Scholarship Program
Live with roommate or housemate
Page 3 of 9
Household Number: «HH»
3. Student Information
Complete section below for all students applying for the OSP.
Student 1
Student 2
Student 3
______________________
______________________
______________________
______-_____-______
______-_____-______
______-_____-______
Date of Birth
______/______/______
______/______/______
______/______/______
Gender
Male
Male
Male
Social Security Number
Relationship to You
Is the student
Hispanic/Latino (a)?
Yes
No
Son/Daughter
Foster Child
Grandchild
Niece/Nephew
Other: ____________
Yes
Does the student have
any of the following
challenges?
Will not affect their
chances of receiving a
scholarship.
No
Yes
No
White
Black, African-American
American Indian or
Alaskan Native
Asian
Native Hawaiian or Other
Pacific Islander
Alaskan Native
Asian
Native Hawaiian or Other
Pacific Islander
Alaskan Native
Asian
Native Hawaiian or Other
Pacific Islander
________
________
________
______________________
______________________
______________________
Neighborhood (assigned)
Neighborhood (assigned)
Neighborhood (assigned)
public school
Charter school (public)
Other public school of
choice
Private school
Private school (DCPS)
Home school
Daycare/Not in school
Don’t know
public school
Charter school (public)
Other public school of
choice
Private school
Private school (DCPS)
Home school
Daycare/Not in school
Don’t know
public school
Charter school (public)
Other public school of
choice
Private school
Private school (DCPS)
Home school
Daycare/Not in school
Don’t know
Current School Type
Son/Daughter
Foster Child
Grandchild
Niece/Nephew
Other: ____________
White
Black, African-American
American Indian or
Current Grade
Current School Name
Female
White
Black, African-American
American Indian or
SA
M
Check one or more.
Son/Daughter
Foster Child
Grandchild
Niece/Nephew
Other: ____________
Female
PL
What is the student’s
race?
Female
E
Name of Student
Not applicable (N/A)
Physical disability
Learning disability
Problems understanding
English
Individualized Education
Plan (IEP)
Scholarship Application – (SY 2012-13) – Parts A and B
D.C. Opportunity Scholarship Program
Not applicable (N/A)
Physical disability
Learning disability
Problems understanding
English
Individualized Education
Plan (IEP)
Not applicable (N/A)
Physical disability
Learning disability
Problems understanding
English
Individualized Education
Plan (IEP)
Page 4 of 9
Household Number: «HH»
3. Student Information (continued)
Complete section below for any additional students applying to the OSP.
Student 4
Student 5
Student 6
______________________
______________________
______________________
______-_____-______
______-_____-______
______-_____-______
Date of Birth
______/______/______
______/______/______
______/______/______
Gender
Male
Male
Male
Social Security Number
Relationship to You
Is the student
Hispanic/Latino (a)?
Yes
No
Son/Daughter
Foster Child
Grandchild
Niece/Nephew
Other: ____________
Yes
Does the student have
any of the following
challenges?
Will not affect their
chances of receiving a
scholarship.
Other: ____________
No
Yes
No
White
Black, African-American
American Indian or
Alaskan Native
Asian
Native Hawaiian or Other
Pacific Islander
Alaskan Native
Asian
Native Hawaiian or Other
Pacific Islander
Alaskan Native
Asian
Native Hawaiian or Other
Pacific Islander
________
________
________
______________________
______________________
______________________
Neighborhood (assigned)
Neighborhood (assigned)
Neighborhood (assigned)
public school
Current School Type
Son/Daughter
Foster Child
Grandchild
Niece/Nephew
White
Black, African-American
American Indian or
Current Grade
Current School Name
Female
White
Black, African-American
American Indian or
SA
M
Check one or more.
Son/Daughter
Foster Child
Grandchild
Niece/Nephew
Other: ____________
Female
PL
What is the student’s
race?
Female
E
Name of Student
public school
public school
Charter school (public)
Other public school of
Charter school (public)
Other public school of
Charter school (public)
Other public school of
choice
Private school
Private school (DCPS)
Home school
Daycare/Not in school
Don’t know
choice
Private school
Private school (DCPS)
Home school
Daycare/Not in school
Don’t know
choice
Private school
Private school (DCPS)
Home school
Daycare/Not in school
Don’t know
Not applicable (N/A)
Physical disability
Learning disability
Problems understanding
English
Individualized Education
Plan (IEP)
Scholarship Application – (SY 2012-13) – Parts A and B
D.C. Opportunity Scholarship Program
Not applicable (N/A)
Physical disability
Learning disability
Problems understanding
English
Individualized Education
Plan (IEP)
Not applicable (N/A)
Physical disability
Learning disability
Problems understanding
English
Individualized Education
Plan (IEP)
Page 5 of 9
Household Number: «HH»
4. Complete the following statement
List all children – scholarship applicants and non-applicants – in your household for whom you are the guardian
I certify that I,
OSP Parent/Guardian Name
am the current guardian of the child(ren) listed below:
DOB (mm/dd/yyyy)
/
/
/
/
/
/
/
/
/
/
/
/
Foster Child/Ward of DC
(Check box if applicable)
Why are you applying to the D.C. Opportunity Scholarship Program?
SA
M
5.
PL
E
Child Name(s) (17 and Younger)
CONTINUE TO NEXT PAGE
Scholarship Application – (SY 2012-13) – Parts A and B
D.C. Opportunity Scholarship Program
Page 6 of 9
Household Number: «HH»
6. 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.
Adult 2
Adult 3
_____________________________
_____________________________
_____________________________
______-_____-______
______-_____-______
______-_____-______
____/____/____
____/____/____
____/____/____
Date of Birth (mm/dd/yy)
Gender
Male
Is the adult
Hispanic/Latino(a)?
What is the adult’s race?
Check one or more.
Yes
Female
No
Male
Yes
No
White
Black, African-American
American Indian or
Alaskan Native
Asian
Native Hawaiian or Other
Pacific Islander
Alaskan Native
Asian
Native Hawaiian or Other
Pacific Islander
Alaskan Native
Asian
Native Hawaiian or Other
Pacific Islander
Less than high school
Less than high school
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
SA
M
Does the adult currently
have a job?
Yes
Female
White
Black, African-American
American Indian or
Since beginning work as an
adult, about how many
years and months has the
adult worked?
No
Male
White
Black, African-American
American Indian or
What is the adult’s highest
level of education?
Female
E
Social Security Number
PL
Name of Adult
You
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
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
___________ years, and
___________ years, and
___________ years, and
___________ months
___________ months
___________ months
Yes, full-time job (35 hr+)
Yes, part-time job
Yes, full-time job (35 hr+)
Yes, part-time job
Yes, full-time job (35 hr+)
Yes, part-time job
Not currently working
Not currently working
Not currently working
Scholarship Application – (SY 2012-13) – Parts A and B
D.C. Opportunity Scholarship Program
Page 7 of 9
Household Number: «HH»
6. 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 that are listed on the previous page.
You
Adult 2
Adult 3
Name of Adult
(from previous page)
_____________________________
_____________________________
_____________________________
Self
Relationship to you
Marital Status
& Date (mm/yy)
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: ______
Other: ______________
PL
Spouse
Parent/Step-Parent
Boyfriend/Girlfriend
Son/Daughter (18+)
Grandparent
Other: ______________
Spouse
Parent/Step-Parent
Boyfriend/Girlfriend
Son/Daughter (18+)
Grandparent
E
7. In the past 12 months, did any members of your household listed on this application receive SNAP
(formerly Food Stamps) and/or public assistance payments, welfare benefits (ex. TANF/GC)?
Yes
No
Not Sure
Do not fill out chart below. Complete ESA Statement Release Form.
SA
M
Fill out income chart below for all adults.
Fill out income chart below for all adults and complete ESA Statement Release Form.
Income Sources (2011)
You
Adult 2
Adult 3
No income received
Filed (or will file) federal tax return
$___________________
$___________________
$___________________
Child support or alimony payments
Monetary gifts from family/friends
Other income: ________________
WILL NOT file tax return: total
wages, salaries, tips earned
Social Security Income, pensions,
retirement, veterans’ benefits
Disability benefits (include SSI for
dependents)
To determine eligibility, you are required to provide official documentation with 2011 annual amounts.
Scholarship Application – (SY 2012-13) – Parts A and B
D.C. Opportunity Scholarship Program
Page 8 of 9
Household Number: «HH»
8. 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
Home Phone
Work Phone
Cell Phone
Email
SA
M
Cell Phone
Name
PL
Student Contact
E
Relationship to You
CONTINUE TO NEXT PAGE
Scholarship Application – (SY 2012-13) – Parts A and B
D.C. Opportunity Scholarship Program
Page 9 of 9
Household Number: «HH»
Part C: Current School Information
Instructions
•
•
•
This section must be completed for each student listed on the first page of your scholarship application.
A separate questionnaire must be filled out on behalf of each student applying for the scholarship.
Do not leave any questions blank.
Name of Student
Yes
Go to question 5.
E
1. Is this student currently in daycare or not yet enrolled in school?
No
Go to question 2.
Check one box below.
Excellent (A)
Good (B)
Fair (C)
Unsatisfactory (D)
Failing (F)
SA
M
PL
2. What overall grade would you give this child’s current school?
3. How satisfied are you with the following aspects of this child’s 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 school ...............................
i.
Discipline .................................................................
j.
Academic quality .....................................................
k.
Racial mix of students ..............................................
l.
Services for students with special needs .................
Check here if not applicable
Scholarship Application – (SY 2012-13) – Part C
D.C. Opportunity Scholarship Program
Page 1 of 3
Household Number: «HH»
4. Approximately how much homework is assigned to this child on an average day?
Check one box below.
0 - 30 minutes
30 minutes to 1 hour
1 to 1½ hours
1½ to 2 hours
1½ to 2 hours
2 to 2½ hours
More than 2½ hours
Don’t know
5. In the past MONTH, how often did you do the following?
Check only one box for each question below.
Once
2 or 3 Times
4 or 5 Times
6 or More Times
E
Never
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 ................
SA
M
PL
a. Help this child with his or her homework .........
6. What will be the most important considerations in your choice of schools?
Read the list of considerations, then rank your top 3 priorities when choosing a school by writing the corresponding
letter in the section below. Choose only three priorities.
List of Considerations When Choosing a School
a.
b.
c.
d.
e.
f.
Location of school
School safety
Class sizes
School facilities
Respect between students and teachers
How much teachers inform parents of students’ progress
g.
h.
i.
j.
k.
l.
Parental involvement in the schools
Discipline
Academic quality
Racial mix of students
Services for students with special needs
How much students can observe religious traditions
Most Important Considerations
1. First Priority
2. Second Priority
3. Third Priority
Scholarship Application – (SY 2012-13) – Part C
D.C. Opportunity Scholarship Program
Page 2 of 3
Household Number: «HH»
7. Do you know which school(s) you would like your child to apply to for Fall 2011?
If this child is awarded a scholarship, you will also need to apply to a participating private school in order to use their
scholarship.
No
Yes (Please list the schools below in order of your first, second, and third preference.)
a. First choice school
b. Second choice school
Certification
PL
8.
E
c. Third choice school
SA
M
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
Scholarship Application – (SY 2012-13) – Part C
D.C. Opportunity Scholarship Program
Parent/Guardian Name (Print)
Date
Page 3 of 3
File Type | application/pdf |
File Title | OMB Approved |
Author | donna.hoblit |
File Modified | 2016-03-03 |
File Created | 2012-02-07 |