Shawmut Education Student Application

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Please answer all questions and submit with a completed referral form from a service provider. If you need help obtaining a referral please let us know at 617-532-1906. Your application will be complete once the referral form is received.
 
 

Student Application

 
 
1.  LAST NAME 
 
 
2.  FIRST NAME 
 
 
3.  MIDDLE INITIAL 
 
 
4.  DATE OF BIRTH 
 
 
5.  STREET ADDRESS 
 
 
6.  SOCIAL SECURITY 
 
 
7.  APT/ROOM# 
 
 
8.  CITY 
 
 
9.  STATE 
 
 
10.  ZIP CODE 
 
 
11.  PHONE NUMBER 
 
 
12.  NAME OF PERSON TO CONTACT IN EMERGENCY 
 
 
13.  RELATIONSHIP 
 
 
14.  ADDRESS 
 
 
15.  PHONE NUMBER 
 
 
16.  LAST GRADE COMPLETED 
  7
  8
  9
  10
  11
  12
  COLLEGE 1
  COLLEGE 2
  COLLEGE 3
  COLLEGE 4
 
17.  BRIEFLY STATE YOUR REASONS FOR WANTING TO ATTEND  
 
 
  TO BE COMPLETED BY OFFICE 
 
18.  REFERRING AGENCY 
 
 
19.  CASEWORKER NAME 
 
 
20.  START DATE 
 
 
21.  APPLICATION RECEIVED DATE 
 
 
22.  STUDENT NUMBER 
 
 
23.  RESERVATION NUMBER 
 
 
24.  INSTRUCTOR 
 
 
25.  LIFE LEVEL 
  GED
  HS DIPLOMA
  VETERAN
  CHILDREN
 
26.  NUMBER OF CHILDREN 
 
 
27.  CHILDCARE NEEDED 
 
 
28.  SITE DESIGNATION 
  TIMOTHY SMITH CENTER
  ALLSTON NEIGHBORHOOD NETWORK
  CAMBRIDGEPORT
  COMMUNITY LEARNING CENTER
 
29.  TYPING SPEED (WPM) 
  10 - 20
  20 - 30
  30 - 40
  40 - 50
  50 - 60
  60 - 70
  80 OR MORE
 
   
 
 
THANKS!
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