Panola Charter

Early College High School

2010-2011

Student's Name: Last:         First:      Middle:       Grade: 12 11 10 9 8

Address:       City:    State: TX LA        Zip Code:

Date of Birth: 00 01 02 03 04 05 06 07 08 09 10 11 12   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000          Social Security Number:

Telephone Numbers: Home         Work    Cell

Ethnicity: American Indian or Alskan Native Asian or Pacific Islander African American Hispanic White

Parent Information:      Mother Father              Enrolling Parent: YES NO

Name: Last: First: Middle: 

Address:  City:     State:  

Telephone Numbers: Home         Work    Cell

Place of Employment:

Email address: (required)

Parent Information:      Mother Father              Enrolling Parent: YES NO

Name: Last: First: Middle: 

Address:  City:     State:  

Telephone Numbers: Home         Work    Cell

Place of Employment:

Email address:

Guardian Information(Person with whom you live if not parent)   Enrolling Parent: N/A YES NO  

Name: Last: First: Middle: 

Address:  City:     State:

Telephone Numbers: Home         Work    Cell

Place of Employment:

Email address: