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 416Sept 22-Nov 17 Mondays & Thursdays 6:00PM - 9:30PM
$1,128.00

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
County
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
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.

I acknowledge.
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.

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EKG Registration Form

Ethnicity and Race

Special Population Information

Refund Policy