Berkshire Educational Opportunity Center Referral Form

Referring Agency Information

Name *

First Name

Last Name

E-mail *

Agency/Organization/Company *

Is your agency/organization a federal TRIO program? *

Yes

Would you like us to follow up with you after we make contact? *

Yes

What is the specific follow up you would like?

Referral Information

Client/Student Name *

First Name

Last Name

Client/Student E-mail

Client/Student Phone #

Client/Student Birth Date or Approximate Age *

Has client/student completed a bachelor’s degree? *

Yes

Don't know

Has client/student provided permission for the Berkshire EOC to contact them? *

Yes

Referral Type

I understand that MassEdCO/Berkshire Educational Opportunity Center’s mission is to provide access to educational and career opportunities that empower people from diverse backgrounds to achieve their potential. I believe that the above-named person would benefit from participation in the following services to meet their educational and/or career goals. Check all that apply.

Career goal-setting

Earning a high school equivalency diploma (GED/HiSET)

English language classes (ESOL)

Selecting a college or training program

Completing admissions and financial aid application paperwork

Assistance in locating other academic support services

Student financial literacy, loan counseling and/or rehabilitation

Other...

Referral Type Other...

For questions, please contact Nancy Stoll:
; 413.347.5115; 141 North Street, Suite 4, Pittsfield, MA 01201

18 Chestnut Street, Suite 210 • Worcester MA 01608 • 508-754-6829 • Fax: 508-797-0069 •

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Berkshire Educational Opportunity Center Referral Form

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