DC School Choice Incentive Program

FOR SOC USE ONLY
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Date:
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Scholarship Application

D.C. Opportunity Scholarship Program

Thank you for your interest in the D.C. Opportunity Scholarship Program (OSP). This application must be completed by the parent or guardian who lives with the child(ren) applying for a scholarship.

Instructions

• Fill out ALL pages of this form

• Submit additional documents via your online parent portal at http://www.ospfamilyportal.force.com

• You will receive an email or a letter in the mail with the status of your application

Section 1: Parent Guardian and Residence Information

Parent/Guardian First and Last Name: ___________________________________________________________

Physical Address (No PO boxes): _______________________________________________________________

City: _________________________________ State: ______ Quadrant: ________ Zip Code: _________________

*If your Mailing address is different than your physical address, please enter the mailing address below:

Mailing Address: _______________________________________________________________

City: _________________________________ State: ______ Quadrant: ________ Zip Code: _________________

Mobile Phone: ________________________________ Home Phone: ________________________________

Work Phone: ____________________________ Email Address: ______________________________________

Preferred Phone Number:		 Home		 Work		 Mobile
Preferred Contact Method		 Email		 U.S. Mail

*If you select Email as your preferred contact method, it will be used as the primary means of communicating with you, so please check your email often for important updates, missing documents and deadlines.

Section 2: Household Information

In the table below, please list ALL ADULTS (18 and older), including yourself, that live in your residence. If any of these adults share finances with you, please indicate by checking the box under “Part of Financial Household.” Your financial household includes people who are a part of or contribute to your household expenses, including adult dependents listed on your income taxes.

Adult Name(s) (18 and Older)		DOB (mm/dd/yyyy)		Part of Financial Household in 2019 Check box if applicable	Social Security Number or Tax ID number (if known and if part of financial household)
YOURSELF		/ /			- -
		/ /			- -
		/ /			- -
		/ /			- -
		/ /			- -
		/ /			- -
		/ /			- -

In the table below, list ALL CHILDREN (17 and younger) that live in your residence. Indicate if you are 1) the legal guardian of the child(ren), and 2) if you are applying for, or renewing an application for the child.

Child Name(s) (17 and younger)		DOB (mm/dd/yyyy)		Check to Certify Guardianship*	Check if Applying/Renewing
		/ /			
		/ /			
		/ /			
		/ /			
		/ /			
		/ /			
		*By checking the guardianship box, you certify that you are the current legal guardian of this child. You may only apply for a child if you are the guardian.

Section 3: Student Information

Please complete the sections below for all the students you indicated you are applying or renewing for on page 2.

	Student 1	Student 2	Student 3
Students Name
Students Social Security Number (If known)
Gender	Male Female	Male Female	Male Female
Relationship to You	Son/Daughter Grandchild Niece/Nephew Foster Child/Ward of DC Other:	Son/Daughter Grandchild Niece/Nephew Foster Child/Ward of DC Other:	Son/Daughter Grandchild Niece/Nephew Foster Child/Ward of DC Other:
What is the student’s race? Check all that apply	White Black/African American Asian Native Hawaiian/Other Pacific Islander American Indian/Alaskan Native Hispanic/Latino(a) Multi-Racial Other:	White Black/African American Asian Native Hawaiian/Other Pacific Islander American Indian/Alaskan Native Hispanic/Latino(a) Multi-Racial Other:	White Black/African American Asian Native Hawaiian/Other Pacific Islander American Indian/Alaskan Native Hispanic/Latino(a) Multi-Racial Other:
Current School Name Write N/A if child is not currently enrolled in school
Current Grade Level (PreK-12)
Current School Type	Traditional Public School Charter School Private School Day Care Home School None	Traditional Public School Charter School Private School Day Care Home School None	Traditional Public School Charter School Private School Day Care Home School None
Does the student have any of the following challenges? Your answers will not affect chances of receiving the scholarship – check all that apply	IEP/ Learning Disability Physical Disability Limited English Ability Other: None	IEP/ Learning Disability Physical Disability Limited English Ability Other: None	IEP/ Learning Disability Physical Disability Limited English Ability Other: None

Section 4: Adult information

Please complete the section below for yourself and all adults you indicated are a part of your financial household on page 2.

Name of Adult	Gender	What is their Race?	What is their Marital Status?	How long has this been their marital status?	Relationship to you
Parent or Guardian Name (Your Name): ________________________________________
	Male Female	White Black/African American Asian Native Hawaiian/Other Pacific Islander American Indian/Alaskan Native Hispanic/Latino(a) Multi-Racial Other:	Single/Never Married Married or Domestic Partner Separated Divorced Widowed	0-6 mo. 6-12 mo. 1 – 2 yrs. 2+ years	YOURSELF
Adult 2: _____________________________________________________________
	Male Female	White Black/African American Asian Native Hawaiian/Other Pacific Islander American Indian/Alaskan Native Hispanic/Latino(a) Multi-Racial Other:	Single/Never Married Married or Domestic Partner Separated Divorced Widowed	0-6 mo. 6-12 mo. 1 – 2 yrs. 2+ years	Spouse/Domestic partner Mother Father Brother Sister Aunt Uncle Friend Neighbor Other
Adult 3: ______________________________________________________________
	Male Female	White Black/African American Asian Native Hawaiian/Other Pacific Islander American Indian/Alaskan Native Hispanic/Latino(a) Multi-Racial Other:	Single/Never Married Married or Domestic Partner Separated Divorced Widowed	0-6 mo. 6-12 mo. 1 – 2 yrs. 2+ years	Spouse/Domestic partner Mother Father Brother Sister Aunt Uncle Friend Neighbor Other

Section 5: Household Sources of Income

Are you or any of the child(ren) you are applying for currently receiving SNAP (formerly Food Stamps) or TANF?

• Yes – Please proceed to section 6 to complete the application. DO NOT FILL OUT THE CHART BELOW.

Please provide your ESA Case Number (if known):_________________________________________

• No/Unknown

Please complete the following chart for yourself and all adults in you indicated on page 2 are a part of your financial household. Please note that in order for us to determine your eligibility you are required to provide official documentation with annual income amounts.

SELECT THE YEAR you are reporting income for:		 2018  2019
Adults Name	Check off all income sources that apply
Yourself	No Income Earned Income/Filing a tax return Earned Income but not enough to file Social Security (such as Retirement or Survivors Benefits (1099-SSA) Supplemental Security Income (SSI) Child Support or Alimony Payments Gifts from Family/Friends above $500 Other Sources:____________________________
Adult 2:	No Income Earned Income/Filing a tax return Earned Income but not enough to file Social Security (such as Retirement or Survivors Benefits (1099-SSA) Supplemental Security Income (SSI) Child Support or Alimony Payments Gifts from Family/Friends above $500 Other Sources:____________________________
Adult 3:	No Income Earned Income/Filing a tax return Earned Income but not enough to file Social Security (such as Retirement or Survivors Benefits (1099-SSA) Supplemental Security Income (SSI) Child Support or Alimony Payments Gifts from Family/Friends above $500 Other Sources:____________________________

Section 6: Alternate Contacts

An alternate contact is someone who we will contact if we are unable to contact you. An alternate contact is someone who will know how to reach you if your contact information changes. Please do not list yourself as an alternate contact. Common examples of an alternate contact is a relative, neighbor and/or family friend. They should have a different number from yourself and one another. We strongly suggest you list at least one alternate contact.

Alternate Contact (1) Name:
Relationship to you:	Boyfriend/Girlfriend Parent Relative	Friend Spouse/Domestic Partner Other:
Home Phone:
Mobile:
Work:
Email:

Alternate Contact (2) Name:
Relationship to you:	Boyfriend/Girlfriend Parent Relative	Friend Spouse/Domestic Partner Other:
Home Phone:
Mobile:
Work:
Email:

Section 7: Language Preference

What language is spoken most often in your home?

	English		Spanish
	French		Tagalog
	Amharic		Hindi/Urdu
	Vietnamese		Other:

Section 8: How Did You Learned about the OSP

How did you first learn about the D.C. Opportunity Scholarship Program (OSP)? Check all that apply

	Family Member or Friend Whose Child is Participating in OSP		Other Family Member or Friend
	Private School(s)		Child’s Current School
	Serving Our Children Event		Letter/Flyer from Serving Our Children
	Community Organization		Church/Religious Organization
	Metro/Bus Ad		Radio
	Social Media, e.g. Facebook		Internet Research
	Newspaper Article or Ad		Other

Section 9: Agreement and Certification

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.

Please check off all of the boxes to verify that you have read, understand, and agree with all of the following statements for each child you are applying for. In submitting this application, I agree to the following for each child named on this application:

• I understand that to be eligible for the D.C. Opportunity Scholarship I must meet certain income guidelines.

• I understand that I must prove current D.C. residency to be eligible for the Program.

• I understand that if eligible, my child’s name may 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 Serving Our Children must keep copies of all documents submitted during the application process to ensure that families are eligible. Serving Our Children will keep this data confidential and will not share any personally identifiable information or data with anyone other than U.S. Department of Education and its contractor(s) for the purposes of evaluating this program or as required by law.

• I understand that Serving Our Children 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 Serving Our Children staff or as required by law.

• I understand that my child and I may be required to participate in all aspects of the evaluation, which may include annual testing of my child, completing annual surveys, and allowing records to be released to the U.S. Department of Education and its contractor(s) for the purposes of evaluating this program. These records may include college entrance exam scores (on the PSAT or SAT exam) from the College Board and college enrollment status from the National Student Clearinghouse and the Federal Student Aid databases.

• I consent to the disclosure of information about my child(ren) and about myself 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 disclose personally identifiable information collected for this evaluation in any publicly available document or database.

• I understand the following:

  • Private schools are generally not subject to the federal Individuals with Disabilities Education Act (IDEA), which requires public schools to provide Individualized Education Programs (IEPs) and other support services for children with special needs.

  • Under D.C. and federal law, a private school cannot discriminate against students with disabilities. In addition, under federal law, a private school may be required to provide auxiliary aids and services for students with disabilities, and make reasonable modifications to policies, procedures and physical buildings to ensure access, with exceptions in some cases where these would fundamentally alter the nature of the school's programs, result in an undue burden, or architectural modifications are not readily achievable. 

  • Under D.C. law, a private school cannot discriminate on the basis of race, color, religion, national origin, sex, age, marital status, personal appearance, sexual orientation, gender identity or expression, familial status, family responsibilities, political affiliation, source of income, or disability of any individual.   However, D.C. and federal laws do not preclude single-sex schools.  

Top of Form

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 Serving Our Children 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		Print Name		Date

• I am interested in receiving materials from OSP Participating Schools. Please provide my name, contact and student grade level information to participating OSP schools.

Privacy Act Statement

Authority - This information is being collected under the authority of The Scholarships for Opportunity and Results Act or “SOAR Act” Division C of P.L. 112-10 as amended by P.L. 115-31, DC Code 38-1853.01 – 38-1853.13.

Purpose - The primary purpose of the information collected is for use in the administration and evaluation of the Department of Education’s (the Department) D.C. Opportunity Scholarship Program. The information is reviewed and then used by Serving Our Children to determine the eligibility of applicants, make a tentative selection, verify application information, and or process applications. Information is also used by the Department to carry out the authorizing statute’s requirement for an evaluation.

Routine Uses – As set forth in the Department’s System of Records Notice (69 Fed. Reg. 22014 dated April 23, 2004), the information you provide will be used by the Department for evaluation purposes. The Department currently has a routine use in the System of Records Notice that permits the Department to disclose records to contractors and expects to modify the System of Records Notice to add an additional routine use in order to allow the Department to disclose records to the College Board and the National Student Clearinghouse in order to obtain applicants’ college entrance exam scores and college enrollment status as part of the Department’s evaluation of the program.

Participation - Providing the personal information requested is voluntary; however, failure to provide this information may result in ineligibility for participation in the program or delays or errors in the processing of the application you have completed.

Social Security Number - Your SSN will only be collected by Serving Our Children and will not be collected by or disclosed by Serving Our Children to any Federal, State, or local education agency.

Paperwork Reduction Act Statement

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. The valid OMB control number for this information collection is 1810-xxxx. 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). If you have any comments concerning the accuracy of the time estimate, suggestions for improving this individual collection, or if you have comments or concerns regarding the status of your individual form, application or survey, please contact U.S. Department of Education, 400 Maryland Ave., SW, Washington, DC 20210-4537 or email [email protected] and reference the OMB Control Number 1810-xxxx. Note: Please do not return the completed scholarship application to this address.

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