EOC Intake Form

May we text you?

Yes

No

Gender Identity

Male

Female

Is English your first language

Yes

No

Are you a U.S. citizen

Yes

No

Did your mother graduate from a FOUR YEAR COLLEGE?

Yes

No

Did your father graduate from a FOUR YEAR COLLEGE

Yes

No

Do you have a career goal?

Yes

No

Military Service (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

Income Level

$0 - 18,735

$18,735 - 25,365

$25,365 - 31,995

$31,995 - 38,625

$38,625 - 45,255

$45,255 - 51,885

$51,885 - 58,515

$58,515 - 65,145

Over $65,145

Select the range of your family’s Taxable income for LAST YEAR

Primary Income Source

Wages/salary

TAFDC (welfare)

SSI or SSDI

No income

Child support

Social Security

Unemployment

Other

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.