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Panola College
Child Care Services
Application for Continuing Assistance
THR-6
Date:
Semester Applying For:
Name (Last, First, MI):
Mailing Address (Street, City, State, Zip):
Phone Number (Cell):
Phone Number (Work):
Relative Phone:
Male
Friend Phone:
Female
Marital Status:
SSN:
Single
Married
Separated
Divorced
Check the program you are enrolled in:
Nursing
Health Information Technology
Occupational Therapy Assistant
Industrial Technology
Cosmetology
Welding
General Business
Office Technology
Computer Information Technology
I wish to remain in the Child Care Services Program.
I do not wish to remain in the Child Care Services Program.
How will you be paying for your college tuition?
A copy of your class schedule is required for each application.
I understand all previous agreements are still in effect.
Student Signature
Stacy Gee, Child Care Services Coordinator
Panola College is an Equal Opportunity Institution that provides educational and employment opportunities on the basis of merit and without discrimination because of race, color,
religion, sex, age, national origin, veteran status, disability or genetic information.
Updated 4/1/2014