EKG WCE Registration Form

EKG Registration Form

Office phone: 903-693-2067 email: ce@panola.edu
Class choices *
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EKG Technician - W. C. Smith Building RM 416February 3rd-April 7th:Mondays & Thursdays 6:00PM - 9:30PM
$1,098.00

Total

$0.00
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 photo of your Drivers License or State ID, copy of your high school diploma/GED Certificate, Social Security Card and any other information requested.

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Signature

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EKG Registration Form

Ethnicity and Race

Special Population Information