Massachusetts Education & Career Opportunities, Inc.-EOC-Application Form

MassEdCO - EOC Intake Form 2024 – 2025
(Site Location: {site_location})
(All information is kept confidential)

Site Location*

Today's Date*

mm-dd-yyyy

Name*

First NameMILast Name

Email*

example@example.com

Address*

Street Address & Apt. #

Apt #

CityState

Zip Code

Phone 1*

(999)999-9999

Mobile*

(999)999-9999

Contact by text?

Yes

Date of Birth*

mm-dd-yyyy

Are you currently in school?

YesNo

If yes, what grade?

If yes, where?

1. Gender Identity*

MaleFemale

2. Ethnicity (check one)*

American Indian / Alaska Native, non-Hispanic/LatinoAsian, non-Hispanic/LatinoBlack or African, non-Hispanic/LatinoHispanic/Latino of any raceWhite, non-Hispanic/LatinoNative Hawaiian or Other Pacific Islander, non-Hispanic/LatinoTwo or more races, non-Hispanic/LatinoNo response

3. Is English your first language?*

YesNo

4. Marital Status*

5. Are you a U. S. Citizen?*

YesNo

A#*

A----------

6. Did your parents graduate from a U.S. 4-year college? - Parent 1*

YesNo

Did your parents graduate from a U.S. 4-year college? - Parent 2*

YesNo

7. Do you have a Career Goal?*

YesNo

If yes, what?

Household Income Level: Please refer to line 15 on the Prior Year Federal Tax Return*

*for more than 8 in family, Add $6,720 for each member

PRIMARY Income Source*

What is the size of your immediate family living with you? (Include yourself and all family members dependent on the income level checked above.)*

Are you? (Check all that apply.)*

Referred by:*

I certify that this information is correct and understand that, by signing this form, I give permission to the Educational Opportunity Center to access my, or my son’s/daughter’s educational past and future enrollment information regarding schools/programs I/he/she has attended in order to track my, or my son’s/daughter’s educational progress. I authorize MassEdCO to contact me regarding MassEdCO’s EOC Program at the phone numbers that I or my son/daughter provide on this form or any future number that I provide for a cell phone or other wireless devices using automated telephone dialing equipment or artificial or prerecorded voice or text messages. I also consent to periodic emails to be sent to me or my son/daughter through email to any addresses that I or my son/daughter provide to MassEdCO.

Student Signature*

Parent or Guardian Signature*