Dental Assisting WCE Registration Form

Dental Assisting Registration Form

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

First NameLast Name
Student ID if applicable
Date of Birth*

MonthDayYear
MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Are you a high school student? If so, you MUST contact Wendy Green at 903-693-1197 or wgreen@panola.edu in order to be registered for this class.

YesNo
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)*

YesNo
Please select the racial category or categories with which you most closely identify. Check as many as apply.*

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite
Special Population Information
Select all that apply*

NoneDisabledHomelessYouth whose parent is active duty armed forcesSIngle parent, including single pregnant womenEconomically disadvantaged families, including low-income youth and adultsOut-of-workforceYouth in or aged out of foster careIndividual lpreparing for nontraditional fieldBarriers to educational achievment, including limited English proficiency
I give Panola College permission to release my directory information.*

YesNo
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.*

YesNo
Please upload a photo of your Drivers License or State ID, Social Security card, High School Diploma/GED Certificate, and any other information requested.

Cancelof
Signature

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Dental Assisting - W. C. Smith Building Rm 416February 4 -April 29, 2025; Tuesday evenings 5:00 PM - 9:00 PM
$1,799.00

Total

$0.00
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Dental Assisting Registration Form

Ethnicity and Race

Special Population Information