All information is kept confidential. Contact Information Name * First Name First Name Middle Name(s) Middle Name(s) Last Name Last Name Generational -- Jr.Sr.IIIIIIIVVVIVIIVIIIIXX Generational Address Country - None -United States Address 1 Address 2 City State - None -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--Armed Forces (Americas)Armed Forces (Europe, Canada, Middle East, Africa)Armed Forces (Pacific)American SamoaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPalauPuerto RicoVirgin Islands ZIP code E-mail * Mobile Phone Contact by Text Yes No Phone Demographics Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Gender Identity * Female Male Ethnicity * 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 Is English your first language? * Yes No Marital Status * Single Married Divorced Separated Widowed Are you a U.S. Citizen? * Yes No A-Number A Did your parents graduate from a U.S. 4-year college? Parent 1 * Yes No Parent 2 * Yes No Do you have a Career Goal? * Yes No Career Goal Family Size * How many people are in your immediate family living with you? (Include yourself and all family members dependent on the income level selected above.) Military 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 Financial Information Income Level * Select the range of your family’s Taxable income for LAST YEAR $0 - 19,140 $19,141 - 25,860 $25,861 - 32,580 $32,581 - 39,300 $39,301 - 46,020 $46,021 - 52,740 $52,741 - 59,460 $59,641 - 66,181 Over $66,182 PRIMARY Income Source * Wages/salary TAFDC (welfare) SSI or SSDI No income Child support Social Security Unemployment Other Signatures 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
