Panola Charter
Early College High School Application
2009-2010

Sender Email address:  (required)

Student Information:
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     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:    Zip Code: 
Telephone Numbers: Home:          Work:     Cell: 
Place of Employment:

Guardian Information(Person with whom you live if not parent)   Enrolling Parent: N/A YES NO  
Name: Last: First: Middle: 
Address:  City:     State:       Zip Code:
Telephone Numbers: Home         Work    Cell
Place of Employment: