JON PETERSON SPECIAL NEEDS SCHOLARSHIP 2024-2025 STUDENT APPLICATION

JON PETERSON SPECIAL NEEDS SCHOLARSHIP 2024-2025 STUDENT APPLICATION

** Student Data Must Match Birth Certificate***
STUDENT INFORMATION

***STUDENT DATA MUST MATCH THE BIRTH CERTIFICATE***
STUDENT FIRST NAME*
STUDENT MIDDLE NAME*
If no middle name please type NONE
STUDENT LAST NAME*
STUDENT DATE OF BIRTH*

MonthDayYear
Date
STUDENT CITY OF BIRTH*
STUDENT GENDER*

MALE
STUDENT NATIVE LANGUAGE*
MOTHERS MAIDEN NAME*
STUDENT LAST FOUR DIGITS SSN #*
CURRENT GRADE LEVEL 2023-2024*
GRADE LEVEL 2024-2025*
STUDENT ETHNICITY: Select Only One*

Asian/Pacific IslanderBlack/Non-HispanicAmerican Indian or Alaskan NativeHawaiian or Other Pacific IslanderMultiracialHispanicWhite/Caucasian/Non-Hispanic
IS YOUR STUDENT REGISTERED FOR HOME SCHOOLING? OR ATTENDING A PRIVATE SCHOOL?
REGISTERED AS HOME SCHOOLED:

YESNO
IF NO, PROVIDE NAME OF PRIVATE SCHOOL STUDENT WILL ATTEND:
TYPE ST. CHARLES PREPARATORY SCHOOL
PRIMARY GUARDIAN INFORMATION
I AM THE (CHECK ONE):*

Natural ParentAdoptive ParentResidential ParentLegal Guardian of student applying for scholarship fundsStudent that is at least eighteen years of age
PRIMARY GUARDIAN FIRST NAME*
PRIMARY GUARDIAN MIDDLE NAME*
If no middle name, type NONE
PRIMARY GUARDIAN LAST NAME*
PRIMARY GUARDIAN DATE OF BIRTH*

MonthDayYear
Date
SSN# LAST FOUR DIGITS*
ADDRESS*

PHYSICAL ADDRESS

Street Address Line 2

CITY, STATE, ZIPState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
E-MAIL*
example@example.com
RELATIONSHIP TO STUDENT*
IN WHAT COUNTY DO YOU LIVE? *
IN WHAT PUBLIC SCHOOL DISTRICT DO YOU LIVE?*
SECONDARY GUARDIAN INFORMATION
SECONDARY GUARDIAN NAME
SECONDARY GUARDIAN MIDDLE NAME
If no middle name please type NONE
SECONDARY GUARDIAN LAST NAME
SECONDARY GUARDIAN DATE OF BIRTH

MonthDayYear
Date
SSN# LAST FOUR DIGITS
ADDRESS

PHYSICAL ADDRESS

Street Address Line 2

CITY, STATE, ZIPState / Province

Postal / Zip Code
PHONE NUMBER
Please enter a valid phone number.
E-MAIL
example@example.com
RELATIONSHIP TO STUDENT
PROOF OF ADDRESS
Proof of residency is required of all first year and renewal applicants and must be submitted to the provider with the application.

Parents/Guardians must document residency by supplying the provider with a current (less than 90 days old) utility bill. The utility (electric, gas, water, sewer, cable/internet) bill MUST SHOW MATCHING SERVICE AND MAILING ADDRESS in the name of the parent/guardian. Post office boxes (except in rural areas where residents only have a PO Box) and cell phone bills have no service address and therefore are not accepted.

Other Acceptable Documents: A monthly mortgage statement (less than 90 days old) OR lease/rental agreement (signed by lessee and lessor) AND a piece of current business mail (examples: pay stub, bank statement, insurance statement, car payment statement, etc) with parent/guardian’s name and address. ***Additional information can be found on the scholarship webpage. ***
AUTHERIZATION AND RELEASE OF INFORMATION
1.The information provided on the application is true and accurate;

2.I have submitted only one Jon Peterson Special Needs Scholarship application for this student;

3.I have received the profile of the provider’s special education program required by division (B) of section 3310.521 of the Ohio Revised Code (ORC) and rule 3301-101-09 of the Ohio Administrative Code (OAC);

4.I have received the comparison document required by section 3323.052 of the ORC, and I understand that acceptance of a scholarship relieves the school district of residence and the school district in which the student is entitled to attend school, if different, of the obligation to provide the child with FAPE;

5.I understand that acceptance of a scholarship after the receipt of the comparison document is informed consent to the provisionsof sections 3310.51 to 3310.64 of the ORC and to the provisions of the rules in this chapter;

6.I will inform the provider, my district of residence, and the department immediately of any change in the student’s residential address, contact information or custody status;

7.I will inform the department, my provider and my district of residence of my withdrawal from the program and the return to the public school system;

8.I will inform the department of the addition or change of a selected service provider;

9.I will sign all scholarship checks received by my providers for my student in a timely manner. I understand that if I fail to endorse the scholarship checks to the provider, I will be responsible for paying the student’s tuition and fees;

10. I understand that the scholarship can only be used for my child’s tuition and services agreed upon between provider and parent;

11. I understand that the scholarship can only be applied to the tuition and fees of the provider(s), and that I will be required to pay tuition and services that exceed the amount of the scholarship and services and costs as prescribed by the policies of the provider;

12. I understand that my student will not be eligible to receive scholarships in subsequent years if the student fails to take required assessments prescribed for the student’s grade level under section 3301.0710 or 3301.0712 of the ORC;

13. I agree to abide by the dispute resolution process described in rule 3301-101-12 of the OAC;

I authorize the Ohio Department of Education and Workforce, my school district of residence, the district of my nonpublic school and my selected providers to share the following information regarding my child: current and past Individualized Education Program (IEP), Evaluation Team Report (ETR), data for the IEP and ETR development including progress and interim reports.
BY SIGNING BELOW, I AGREE TO ALL THE ABOVE STATEMENTS.

I AUTHORIZE: St. Charles Preparatory School to apply on my behalf for the Jon Peterson Scholarship Program through the Ohio Department of Education's electronic application system.
Signature of Primary Guardian

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Upload birth Certificate here.

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Upload a proof of address here. Please make sure to include all pages of utility bills to show both the service address and the billing address.

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Questions/Concerns

Please contact: The SC Finance Office at jp@scprep.org
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JON PETERSON SPECIAL NEEDS SCHOLARSHIP 2024-2025 STUDENT APPLICATION

STUDENT INFORMATION

IS YOUR STUDENT REGISTERED FOR HOME SCHOOLING? OR ATTENDING A PRIVATE SCHOOL?

PRIMARY GUARDIAN INFORMATION

SECONDARY GUARDIAN INFORMATION

PROOF OF ADDRESS

AUTHERIZATION AND RELEASE OF INFORMATION

Questions/Concerns