EKG WCE Registration Form

EKG Registration Form

Office phone: 903-693-2067 email: ce@panola.edu
If Dual Credit Student, please enter high 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.
I authorize Panola College to photograph me, in both still and motion picture form, and consent to the exhibition of such photographs and recordings in advertising and in publicity used in connection with Panola College. I hereby release Panola College from any and all liability, claims or causes of action, arising out of, or created by, the use of my image, name and voice in photographs, still and motion pictures, as set forth above. This authorization, consent and release shall apply to all photographs, still and motion pictures, taken with my knowledge and acquiescence, from the date hereof until I give Panola College written notice of termination.
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 be given after that time. Means of notification include: in writing by e-mail (ce@panola.edu) 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.
Class choices
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EKG Technician - Fall Session
September 2nd - December 9th, 2026: Wednesday, 5:00PM - 8:30PM

$1,200

EKG Technician Dual Credit High School Students
Fall 2026: September 2nd - December 9th, 2026: Wednesday, 5:00PM - 8:30PM

$640
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.

Submitting form without required attachments will result in an incomplete application. Only completed applications will be able to move forward.
Cancelof
Signature
Should be Empty:

EKG Registration Form

Ethnicity and Race

Special Population Information

Refund Policy

Class choices *

Class choices