MassEdCO - EOC Intake Form
(Site Location: {site_location})
(All information is kept confidential)
Site Location
Today's Date
-
Month
-
Day
Year
mm-dd-yyyy
Name
*
First Name
MI
Last Name
Email
*
example@example.com
Address
Street Address
Apt #
City
State
Zip Code
hone 1
(999)999-9999
Mobile
(999)999-9999
Contact by text?
Yes
Student phone #
(999)999-9999
Contact by text
Yes
Parent phone #
(999)999-9999
Contact by text
Yes
Are you currently enrolled in college?
Yes
No
Have you ever attended college?
Yes
No
Do you currently have an appointment schedule with an EOC Advisor
Yes
No
Date of Birth
-
Month
-
Day
Year
mm-dd-yyyy
If currently enrolled in high school what high school do you attend
1. Gender Identity
Male
Female
2. Ethnicity (check one)
American Indian / Alaska Native, non-Hispanic/Latino
Asian, non-Hispanic/Latino
Black or African, non-Hispanic/Latino
Hispanic/Latino of any race
White, non-Hispanic/Latino
Native Hawaiian or Other Pacific Islander, non-Hispanic/Latino
Two or more races, non-Hispanic/Latino
No response
3. Is English your first language?
Yes
No
4. Marital Status
Single
Married
Divorced
Separated
Widowed
5. Are you a U. S. Citizen?
Yes
No
A#
A----------
6. Did your parents graduate from a U.S. 4-year college? - Parent 1
Yes
No
Did your parents graduate from a U.S. 4-year college? - Parent 2
Yes
No
7. Do you have a Career Goal?
Yes
No
If yes, what?
Income Level: Check the range of your family’s Taxable income for LAST YEAR.
$0-$21,870
$21,871-$29,580
$29,581-$37,290
$37,291-$45,000
$45,001-$52,710
$52,711-$60,420
$60,421-$68,130
$68,131-$75,840
over $75,841
*for more than 8 in family, Add $6,720 for each member
PRIMARY Income Source
Wages/salary
Child support
TAFDC (welfare)
Social Security
SSI or SSDI
Unemployment
No income
Other
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.)
Veteran of the U.S. armed services
Active Duty Military member
Spouse of Active Duty Military
Child of Active Duty Military
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
*
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