Please read THIS LETTER before completing the survey. Thank you!


What is your living/residential status? (Place an "x" in the box that applies.)

Please place a check on the line beside the number of people in your household:

Do you have children who currently attend Brockton Public Schools? Please list below their name, school, and grade.

What is your Race? Please check one.

Are you of Hispanic or Latino origin?

Please check one.​​
What is your age?​​

What is your gender? Please check one.

Do you receive or have you applied for the following benefits? Please check all that apply.

TANFstands for Temporary Assistance for Needy Families. It is a federally funded grant program that allows states to create and administer their own assistance programs for families in need. TANF replaces the federal programs previously known as “welfare”.

WIC stands for Women, Infants, and Children. WIC is a supplemental nutrition program administered by the Food and Nutrition Service (FNS) division of the U.S. Department of Agriculture.

Supplemental Security Income (SSI) is a Federal income supplement program funded by general tax revenues. It is designed to help aged, blind and disabled people, who have little or no income and it provides cash to meet basic needs for food, clothing, and shelter.

(formerly Food Stamps)

SNAP benefits are provided by the federal government and administered by DTA. Residents of the Common-wealth who participate in SNAP are families with children, elders and disabled.

There are different types of low cost housing such as subsidized rental housing, public housing and homeownership opportunities for low-income, first time home buyers.

Do you need assistance in applying for any of the above benefits? Please check one.

Electronic signature of the person completing the survey. By typing your name above, you are signing this survey.

In case of questions contact Janice Johnson-Plumer, Community Outreach Specialist

Brockton Public Schools,

43 Crescent Street, Brockton, MA, 02301 (508) 208-5518

* All information obtained will remain confidential *

Please provide an email address where we can send a link to your current form.

Email Address :