Co- Enrollment and Community Enrichment WCE Registration Form

Workforce and Continuing Education Registration Form

Office phone: 903-693-2067 email: ce@panola.edu
Name

First NameLast Name
Maiden Name if applicable
Student ID
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Ethnicity and Race
Are you Hispanic or Latino? (a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)
Please select the racial category or categories with which you most closely identify. Check as many as apply.
Special Population Information
Select all that apply
I give Panola College permission to release my directory information.
I agree to abide by the college copyright agreement and release. I also affirm that policies concerning disclosure of directory information as well as information related to Bacterial Meningitis (Senate Bill 31) were made available.

Workforce and Continuing Education Registration Form