Success Boston Coaching - Student Intake Form

Thank you for taking the time to answer these questions. Your answers will help us to make your college experience stronger.

-The Success Boston Coaching Team

Basic Student Details

Home Address & Contact

Ethnic Background

Parent/Guardian's Education

Long Term Contacts
List two people who will know where you are in five years, who may or may not be family members. Please provide at least one contact.
Contact 1

Contact 2

College Plans: You are almost finished! Just a few more questions for you. Please be thoughtful and honest when answering these.

College Plans


Intended Major

Additional Information

By submitting this form, I consent to the use of information provided in this form and my student records for research purposes, to inform strategies to strengthen the Success Boston program and improve student outcomes. I understand that my information may be made available to Success Boston partners including but not limited to the Boston Foundation and affiliated researchers. I also understand that by providing my cell phone number, I agree to receive text messages as a part of my participation in Success Boston.

Protecting your privacy is very important. Only authorized persons will have access to your information, except as required by law. Your personal records will be kept strictly confidential by all parties to whom access is granted. Your name will never be used publicly, nor will any description that could identify you.

Sharing your information is voluntary. You can still take part in Success Boston even if you do not consent to the use of your information for program improvement and research purposes.  For questions or concerns or if you do not want your information to be used for research or evaluation purposes please contact or call 617-338-4036.

Thank you for taking the time to complete this entire questionnaire. Your answers are important to us. Good luck as you prepare for and begin college!

 - The Success Boston Coaching Team