Massachusetts Education & Career Opp-TS #102-Application Form

Today's Date

mm-dd-yyyy

Student Name*

First NameMiddle InitialLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Apt. #

Student Phone:

(999)999-9999

Student Email Address*

example@example.com

Parent Email Address

example@example.com

Student Date of Birth*

mm-dd-yyyy

Are you a U.S. citizen?*

YesNo

If No, Alien Registration No.:

A

Other Resident Status:

Gender Identity:*

FemaleMale

Race/Ethnicity*

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

School:*

Current Grade:*

Your Family Size (including yourself):*

Did the parent(s) with whom you live graduate from a four-year college?*

YesNo

If yes, name of parent 1 college:

If yes, name of parent 2 college:

Primary Income/Support Sources - pertaining to parents/guardian (or student if independent) Please check only one:*

Income Level: Check the range of your family's taxable income for the previous year.*

Parent/Guardian/Release of Information: *I certify that the information is correct and understand that by signing this form, I give permission to the Educational Talent Search Program to access my child's educational enrollment in order to track their educational progress. I authroize MassEdCO to contact me regarding the Talent Search Program. I also consent to periodic e-mails, and texts to be sent to my child through email/phone provided to MassEdCO.

Parent or Guardian's Signature*

Date

mm-dd-yyyy

Student Signature:

Date

mm-dd-yyyy

MassEdCO Educational Talent Search Program Application 2024-2025

Student Information

Family Information