Massachusetts Education & Career Opp-EOC #1651-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 #

CityState

Zip Code

Phone 1*

(999)999-9999

Mobile

(999)999-9999

Contact by text?

Yes

Date of Birth*

mm-dd-yyyy

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?

Income Level: Check the range of your family’s Taxable income for LAST YEAR.*

*for more than 8 in family, Add $8070 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.)

Veteran of the U.S. armed servicesActive Duty Military memberSpouse of Active Duty MilitaryChild 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*