Project Greater Opportunities /Project Excel
Parent Information for Student Application (Please print in ink)
*The information on this form is required by program regulations. It is kept confidential. Please call
(978) 630-9248 if you have any questions completing this form.
Student Name: _____________________________ School: _____________________ Grade: ________
Student Social Security Number _______________________________
Mother’s First Name: ____________________________ Father’s First Name: ___________________________
Mother’s Last Name: ____________________________ Father’s Last Name: ___________________________
Mother’s Mailing Address: _______________________ Father’s Mailing Address: _______________________
City, State, Zip: _______________________________ City, State, Zip: _______________________________
Mother’s Email Address: ________________________ Father’s Email Address: ________________________
Mother’s Work Number: ________________________ Father’s Work Number: ________________________
Language Spoken at Home: _____________________ Language Spoken at Home: _____________________
Parent/Guardian Educational Background
Did either parent graduate from a four-year college? _______Yes ______No
Name of College Type of Degree Earned
Parent/Guardian Financial Information
Do you qualify to receive free or reduced lunch at school? ___________
Indicate your family’s taxable (not gross) income range for the last calendar year:
$0 - $13,470 $27,601 - $32,310 For returns filed for 2002 you may find
$13,471 - $18,180 $32,311 - $37,020 your taxable income on:
IRS Form 1040, line 41
$18,181 - $22,890 $37,021 - $41,730 IRS Form 1041A, line 27
IRS Form 1040EZ, line 6
$22,891 - $27,600 $41,731 - $46,440
$46,441 and over
Taxable income is the dollar amount after all adjustments, deductions and exemptions have been applied.
Examples of these adjustments include head of household deductions, child credits, and educational expense
If you were not required to file a return based on the amount of money you earned in 2002, your
taxable income would be 0.
Please call Project GO at (978) 630-9248, if you need assistance completing this form.
Please turn over and complete other side
List family members in your household other than yourselves and the above named student
First Name Last Name Relationship to School Grade In
Student in GO/Excel
Certification and Release of Information
I certify that all information provided above is correct and give consent for Project GO/Excel to secure and
review all information, including academic transcripts, needed to provide educational services to the student
names above, while he/she is enrolled in Project GO/Excel.
Parent/Guardian Signature: ________________________________________ Date: ______________
I, being the parent or guardian of the above-named student, give permission for Project GO and Project Excel
to use pictures, videotapes and audio recordings of the above-named student. I also give permission for
Project GO and Project Excel to use the pictures, videotapes and audio recordings in program publications
and in articles that may appear in local newspapers or other publications.
Parent/Guardian Signature: _________________________________________ Date: ________________
I do NOT give permission for Project GO/Excel to use pictures, videotapes and audio recordings of the
A College Access and Preparation Program of Mount Wachusett Community College.
Mount Wachusett Community College is an
Affirmative Action/Equal Opportunity Institution