Preview Day Registration Form

Preview Day Registration Form

We are excited to host you on campus. Please help us prepare by completing the following.

Student Information
Participant Name*

First NameLast Name
Gender*
Age*
Date of Birth*

MonthDayYear
School Attending*
Grade*
T-shirt Size*
We will be serving snacks. Tell us your food Restrictions/ allergies.*
What would you like your campus tour to concentrate on?

CosmetologyHealth SciencesEnergy: HVAC, Welding, Electrical, PetroleumFine Arts: Theater, Band, ChoirGeneral Academics
Are you interested in living on campus?

YesNoMaybe

Student Contact Information
Mobile Phone
Home Phone
E-mail
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Liability Information
MEDIA RELEASE

I hereby authorize Panola College to photograph me, my child/children and any subject matter owned by me or my child/children, in still picture and motion picture form, and to record my voice or my child’s/children’s voice(s), or to cause such photographs and pictures and recording to be made. I hereby consent to the exhibition of such photographs and pictures and the use of my name(s) and voice(s) or my child’s/children’s name and voice by you, the world, whether such exhibition and use are sponsored or not. I also consent to the use of such photographs, the right to use my or my child’s/children’s name(s), voice(s) and photographs and pictures in advertising and in publicity in connection with a subsequent exhibition, and in the exhibition itself.

I hereby release you and all other parties from any and all liability, claims or causes of action, arising out of, or created by, the use of my or my child’s/children’s photograph or photographs, picture or pictures, and name(s) and voice(s), as set forth above.

This authorization, consent and release shall apply to all photographs, pictures and recordings of the below-signed, made with the knowledge and acquiescence of the below-signed, from the date hereof until the below-signed shall give you written notice that this authorization, consent and release is no longer effective. This agreement shall be binding on me, my heirs, administrators and executors, and shall inure to the benefit of you, your successors, assigns or licensees.

By signing below, you agree to the media release above.

Signature
By signing and submitting this registraiton form, you understand and agree to all policies.

Once you click "Register" you will be redirected to pay the registration fee. You may use your credit/debit card or PayPal account to pay the fee.
Student Signature*

First NameLast Name
Today's Date*

MonthDayYear
Date
Should be Empty: