Workforce and Continuing Education Registration Form
Office phone: 903-693-2067 email: ce@panola.edu
Name
*
First Name
Last Name
Maiden Name if applicable
Student ID
Date of Birth
*
Please select a month
January
February
March
April
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June
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Month
Please select a day
1
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31
Day
Please select a year
2026
2025
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1999
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1938
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1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / 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)
*
Yes
No
Please select the racial category or categories with which you most closely identify. Check as many as apply.
*
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Special Population Information
Select all that apply
*
None
Disabled
Homeless
Youth whose parent is active duty armed forces
SIngle parent, including single pregnant women
Economically disadvantaged families, including low-income youth and adults
Out-of-workforce
Youth in or aged out of foster care
Individual lpreparing for nontraditional field
Barriers to educational achievment, including limited English proficiency
I give Panola College permission to release my directory information.
*
Yes
No
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.
*
Yes
No
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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.
*
I understand and agree.
Class choices
*
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( X )
Music - Instrumental; September 8 - December 11, 2026
J. Bogs Carthage FBR TBA
$195.00
$
195.00
Flute
Clarinet
Bass Clarinet
Saxophone
Trumpet
French Horn
Trombone
Baritone/Euphonium
Tuba
Percussion/Drums
Piano
Guitar
Other:
Substitute Teacher/Paraprofessional Basic Training; September 1 - October 16, 2026
ONLINE
$250.00
$
250.00
Are you a full-time Panola College Employee?
*
Yes
No
Signature
Payment Information
Call (903) 693-2067 to pay to complete registration.
Submit
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