Pharmacy Technician WCE Registration Form

Pharmacy Technician Registration Form

Office phone: 903-693-2067 email: ce@panola.edu
Class choices *
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Pharmacy Technician - W. C. Smith Building RM 416May 28th-August 6th; Wednesdays 6:00 PM - 9:30 PM
$1,382.00

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
Consent for Background Check

initials * In compliance with the clinical affiliates that require a student background check, I give Panola College permission to perform a background check.
initials* I give Panola College Pharmacy Technician program permission to give copies of the results of my criminal background check to the Clinical Supervisor, Director of Nursing, or Clinical Human Resource Department at the site I am attending when requested.
Signature

Clear
PHARMACY TECHNICIAN PROGRAM ELIGIBILITY INFORMATION

Criminal Background Check

Successful completion of a criminal background check is required for admission into the Panola College Pharmacy Technician program. The background check will include a seven year felony and misdemeanor criminal record search.

The following histories will disqualify an individual from consideration for admission because the student would not be eligible for clinical placement: (this includes, but is not limited to):
- Registered sex offenders
- Felony convictions
- Felony deferred adjudication involving crimes against persons (physical or sexual abuse)
- Known or observed abuse or neglect of patients/clients/customers
- Observed or proven theft
- Convictions of violent acts (misdemeanors or felonies)
- Misapplication of fiduciary property or property of a financial institution (Class A misdemeanor or felony)
- Securing execution of a document by deception (Class A demeanor or felony)
Disclaimers
- Successful completion of a background check does not ensure eligibility for licensure or future employment.
- Clinical agencies can establish more stringent standards, if they so desire, to meet regulatory requirements for their facility.
- Clinical agencies can conduct additional background checks at their discretion.
- If a student is found to be ineligible for clinical placement any time during the program, the student is unable to meet clinical learning objectives and will be withdrawn from the program.
First Name Last Name
Signature

Clear
PHARMACY TECHNICIAN

BACKGROUND/DRUG SCREENING

I give Panola College permission to perform a background search from the following websites prior to registering for the Pharmacy Technician program:
1. Public Data
2. Texas Department of Public Safety - Criminal History background
If I am married or have been married and divorced, I also give Panola College permission to perform a Criminal Background check on my maiden name as well as my married name(s).

My admission into the Pharmacy Technician program is ultimately determined by the findings of the above (2) searches and those findings will be final. I have been provided with a copy of the Pharmacy Technician Program Eligibility requirements.

FULL NAME   LAST*   FIRST*   MIDDLE   MAIDEN
Other names used
Date of Birth*      RACE*   Gender*
Signature

Clear
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
Should be Empty:

Pharmacy Technician Registration Form

Ethnicity and Race

Special Population Information

Consent for Background Check

PHARMACY TECHNICIAN PROGRAM ELIGIBILITY INFORMATION

Criminal Background Check

Disclaimers

PHARMACY TECHNICIAN

BACKGROUND/DRUG SCREENING