Appendix K OSP Consent Form

Appendix K OSP Consent Form.pdf

DC Choice Evaluation

Appendix K OSP Consent Form

OMB: 1850-0800

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1850-0800 can be found here:

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OMB: 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)

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

First

Middle

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



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 ICDocketMgr@ed.gov 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

•

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 info@dcscholarships.org
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

City

Parent/Guardian Name (You)

Home Phone

Work Phone

Cell Phone

SA
M

2. Current Residence Information

a. How many people live in your residence?

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

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

________

______________________

 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




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

What is the student’s
race?

 Female

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

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

________

______________________

 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

What is the student’s
race?

 Female

Name of Student

public school

 Charter school (public)
 Other public school of

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

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

 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

Social Security Number

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

___________ months

 Yes, full-time job (35 hr+)
 Yes, part-time job

 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: ______________







Spouse
Parent/Step-Parent
Boyfriend/Girlfriend
Son/Daughter (18+)
Grandparent

Other: ______________








Spouse
Parent/Step-Parent
Boyfriend/Girlfriend
Son/Daughter (18+)
Grandparent








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



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

SA
M

Cell Phone

Name

Student Contact

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.

1. Is this student currently in daycare or not yet enrolled in school?





Go to question 2.

Check one box below.
Excellent (A)
Good (B)
Fair (C)

Unsatisfactory (D)
Failing (F)

SA
M







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
















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 school ...............................

Discipline .................................................................

Academic quality .....................................................

Racial mix of students ..............................................







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



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

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

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	2012-09-28
File Created	2012-02-07