Dental Assisting WCE Registration Form

Dental Assisting Registration Form

Office phone: 903-693-2067 email: ce@panola.edu
If Dual Credit High School Student, enter school name.
Name

First NameLast Name
Student ID if applicable
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.
TEXAS STATE BOARD OF DENTAL EXAMINERS INFORMATION

Our program meets the requirements to allow you to apply for a license with the Texas State Board of Dental Examiners. In addition to the Panola College Dental Assisting course, successful completion of a criminal background check is required for licensure with the Texas State Board of Dental Examiners. The background check will include a felony and misdemeanor criminal record search, and will include expunged records. This background check is not conducted by Panola College, and Panola College cannot determine your eligibility for licensure beyond providing the classroom education necessary to apply for licensure. If you have questions regarding which convictions disqualify you from licensure, you are responsible for contacting TSDBE and following their process to determine eligibility (licensinghelp@txdbe.texas.gov). Disclaimer: Successful completion of a background check does not ensure eligibility for licensure or future employment.
I acknowledge that I have read and understand the Texas State Board of Dental Examiners criminal background check information and disclaimer:
REFUND POLICY

If Panola College cancels a continuing education class, a full tuition refund will be made. A 100% refund will be issued if you drop a class through the approved means of notification during our normal business hours two-(2) business days prior to the first scheduled class day. (Example: If the class is on Monday, notification must be given on the Thursday prior to the start of the Monday class.) No refund will begiven after that time. Means of notification include: in writing by e-mail (ce@panola.edu), by fax (903-693-1196), or in person at Panola College. (There may be some courses for which refunds cannot be made.) Refunds will take several weeks to process and will be mailed to the student’s listed permanent address.
I acknowledge that I have read and understand the refund policy as stated above.
Class Choices:
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Dental Assisting - Summer Session
June 9th - August 25th, 2026; Tuesday 5PM-9PM

$1,799.00

Dental Assisting Dual Credit High School Student
Fall 2026: September 15th - December 8th, 2026; Tuesday 5PM-9PM

$960.00
You will need to submit a photo or copy of your Drivers License or State ID, High School Diploma / GED Certificate, and your Social Security card.
Please upload a photo of information requested.

Cancelof
Signature
Should be Empty:

Dental Assisting Registration Form

Ethnicity and Race

Special Population Information

TEXAS STATE BOARD OF DENTAL EXAMINERS INFORMATION

REFUND POLICY

Class Choices: