Please complete the form, then click the Submit button. All fields with * must be completed.
Prefix
Legal First Name
Middle
Legal Last Name
Suffix
Address 1
Address 2
City
State
ZIP code
Primary Phone Number
Cell Phone
Date of Birth
Student Work or Personal Email Address
Sex
Parent/Guardian Email Address
Parent/Guardian Phone Number
Are you a veteran of the U.S. Armed Forces ?
Race/Ethnicity-Select as many as apply
Are you Hispanic/Latino?
A. Are you a United States citizen ? If yes, go to section DOCUMENTATION.
Are you a Permanent Resident ?
If yes, list Alien Registration Number
If you are not a U.S. Citizen or Permanent Resident, please state your Visa or immigration status in detail including Home Country.
Please check-off those documents you possess as proof of your intent to remain in Massachusetts
B. I am a member of the armed forces (or spouse or unemancipated child) on active duty in Massachusetts
C. I am not a Massachusetts resident. My home state is :
Type in your First and Last Name as an electronic signature
Date:
Parent/Guardian Signature (Student is under 18 years old)