Language
English (US)
Spanish (Latin America)
Urdu
Português
Ukrainian
Russian
Türkçe
Français
Pashto
Haitian Creole
Arabic
Persian
Punjabi
Bengali
Chinese (Simplified Han)
Vietnamese
Română
Free English Program
Student Registration Form
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
Enter phone number
*
Email
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Sex:
*
Male
Female
Other / Prefer not to disclose
What are your pronouns?
He/Him
She/Her
They/Them
Social Security Number
Are you Hispanic/Latino?
*
Yes
No
What is your race? Check all that apply.
*
Black or African American
Asian
White
Native Hawaiian or Other Pacific Islander
Alaskan Native / American Indian
Country of birth
*
What is your first language (L1)?
*
What is your level of reading/writing proficiency in your first language (L1)?
*
Fluent
Intermediate
Basic
None
What other languages do you speak?
EDUCATION
What is your highest completed level of education? Check one option.
*
No school
Grade 1-5
Grade 6-8
Grade 9-12, no diploma
High School Diploma
High School Equivalent (for example, HiSET or GED)
Some College or University, no degree
College or University degree
Where did you receive your highest level of education?
*
School in the United States
School in another country
Were you ever enrolled in Massachusetts public education (K-12, Adult Education, or Community College)?
*
Yes
No
Do you have a specific learning disability that you want teachers to be aware of?
*
Yes
No
If yes, please explain:
EMPLOYMENT/INCOME
Please select the option that describes you:
*
I have one full-time job. (Full-time = 30 hours or more each week)
I have one part-time job. (Part-time = less than 30 hours each week)
I have multiple jobs.
I am unemployed, but I am looking for work.
I am not looking for work.
I am retired.
What is your job/position?
Where do you work?
How much do you earn per hour?
Enter a dollar amount (for example $15.00)
Approximately how many hours do you work in a week?
FAMILY/HOUSEHOLD
Please select one:
I am married.
I am single.
I am legally separated.
What is the total number of people in your household (adults & children)?
Do you have one or more children under the age of 18?
Yes
No
What are your children's ages?
What is your total family income yearly? Check one option.
$0-$2,999
$3,000-$5,999
$6,000-$8,999
$9,000-$11,999
$12,000-$14,999
$15,000-$19,999
$20,000-$29,999
$30,000-$39,999
$40,000-$49,999
$50,000-$59,999
$60,000-$69,999
$70,000-$79,999
$80,000-$89,999
$90,000-$99,999
$100,000 and up
Do you receive any of the following public assistance benefits? Check all that apply.
*
Mass Health
SNAP (EBT/Food Stamps)
WIC
SSI (Supplemental Security Income)
TAFDC (Transitional Aid to Families with Dependent Children)
EAEDC (Emergency Aid to the Elderly, Disabled and Children)
None
Other
Name of your Emergency Contact - Write the name of the person we should contact if there is ever an emergency.
Emergency Contact Phone Number
Please enter a phone number.
Format: (000) 000-0000.
Submit
Should be Empty: