DC Choice Application

FOR SOC USE ONLY
Guardian ID :
Date:
Location:
Initials:
# of Students:

Scholarship Application

D.C. Opportunity Scholarship Program

2018-19

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:______________________ Zip Code: _________________

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

Mailing Address: _______________________________________________________________

City: _________________________________ State:______________________ 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 2016 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	White Black/African American Asian Native Hawaiian/Other Pacific Islander American Indian/Alaskan Native	White Black/African American Asian Native Hawaiian/Other Pacific Islander American Indian/Alaskan Native
Is the student Hispanic/Latino(a)?	Yes No	Yes No	Yes No
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	IEP/ Learning Disability Physical Disability Limited English Ability	IEP/ Learning Disability Physical Disability Limited English Ability

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?	Are they Hispanic or Latino(a)?	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	Yes No	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	Yes No	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	Yes No	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:		 2016  2017
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:

Source: modified from 2012-2014 and 2019 OSP applications

Section 7: Language Preference

What language is spoken most often in your home?

	English		Spanish*
	Amharic		Hindi/Urdu
	Vietnamese		Other:

*Please note: If you select Spanish, all written communications from today on will be sent to you in Spanish.

Section 8: How 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: School Preference

The information provided in this section is for informational purposes only and will not affect your receipt of an OSP scholarship or admission to schools.

There are many different reasons that parents choose to apply for an Opportunity Scholarship for their child. Are you applying for an Opportunity Scholarship because, compared to your child’s current (or assigned school for next year), you are looking for a school that: [check all that apply]

• a. is closer to home and/or work?

• b. is located in a safer neighborhood?

• c. has a safer school environment?

• d. has smaller class sizes?

• e. is a smaller school?

• f. has better school facilities (for example, gym, art studio, science labs)?

• g. offers extracurricular activities (for example, sports, drama, art, music) that my child would like?

• h. offers religious instruction/environment?

• i. focuses more on developing children’s character or values?

• j. has better academics?

• k. has more students with my child’s racial/ethnic background?

• l. has more students with different racial/ethnic backgrounds than my child?

• m. has more students from families that have a similar income level to my family?

• n. has more students from families that have different income levels than my family?

• o. has better teachers?

• p. has stronger school leadership?

• q. has more parent involvement?

• r. has better services for my child with special needs?

• s. has students who are better behaved or more academically engaged?

• t. offers an academic theme or focus that is a better fit for my child’s interests?

• u. other, please specify: ____________________________________?

Of the reasons your family chose to apply for an opportunity scholarship, which one would you say is the most important to you? [Write the letter from the question above for the most important reason you chose to apply for an opportunity scholarship for your child.]

______________________________

If your child is awarded a scholarship, do you know which private school(s) you would like the child to apply to for Fall 2020? Please list them in the order of your preference.

• 1^st choice school.

• 2^nd choice school.

• 3^rd choice school.

• I don’t know

Section 10: 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 the 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 U.S. Department of Education and its contractors will not disclose personally identifiable information collected for this evaluation in any publicly available document or database.

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 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 U.S. Department of Education to carry out the authorizing statute’s requirement for an evaluation.

Routine Uses - As set forth in the Department of Education’s System of Records Notice (69 Fed. Reg. 22014 dated April 23, 2004), the information you provide will be used by the U.S. Department of Education for evaluation purposes. The U.S. Department of Education currently has a routine use in the System of Records Notice that permits the U.S. Department of Education 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 U.S. Department of Education 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 U.S. Department of Education’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. Public reporting burden for this collection of information is estimated to average 13 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). 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, 550 12^th Street, SW 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.

1 | Page

Scholarship Application Form (SY 18-19)

D.C. Opportunity Scholarship Program