CUNY EDGE Intake Form

Contact Us

Room: M-Building, MB-13
Phone: (718) 482-5479

Monday– Friday 9 a.m.– 5 p.m.
Virtual Office – Fridays

Personal Information

Name(Required)

First Last

Personal Email(Required)

College Email (live@lagcc.cuny.edu)(Required)

Phone(Required)

Address(Required)

Street Address City State ZIP Code

Gender(Required)

Age(Required)

Gender Other

Do you consider yourself Hispanic/Latino/a?(Required)

Race/Ethnicity (Optional)

American Indian/Alaskan Native

Asian/ Pacific Islander

Black

White

Other

Race/Ethnicity (Other)

Current Student Status(Required)

Are you a parent?(Required)

If yes, how many children are under age 18?(Required)

Emergency Contact Name

First Last

Emergency Contact Phone

Emergency Contact Relationship

Public Assistance Status Information

Public Assistance Case Number(Required)

HRA Case Type(Required)

HRA Case Status(Required)

HRA Case Type (Other)

HRA Case Status (Other)

Educational Information

Currently Attending(Required)

Currently pursuing degree(Required)

Major(Required)

Major Other

GPA (cumulative)(Required)

Number of credits taking this semester?(Required)

Currently enrolled in other student support programs(Required)

Currently enrolled in other student support programs (Other)

Are you a transfer student?(Required)

If yes, from what school?(Required)

Work Information

Are you currently (or anticipate to be) enrolled in Federal Work Study?(Required)

Are you currently employed (not internship or work study)?(Required)

If yes, are you working:(Required)

Signature(Required)

Comments

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