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Panola Early College High School

PS Logo

Student Information

School Year Applying For:*

Answer Required

2023-24

2024-25

First Name:*

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Middle Name

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Last Name*

Answer Required

Date of Birth:*

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Gender:*

Answer Required

Male

Female

Student Cell Phone

Number Required

Street Address*

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City*

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Zip/Postal*

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Parent/Guardian Information

First Name:*

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Last Name:*

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Relationship to Student:*

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Father

Mother

Grandparent

Other:

Street Address*

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City*

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Zip/Postal*

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Email Address:*

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Cell Phone:*

Number Required

Home Phone:*

Number Required

Work Number:*

Number Required

CERTIFICATION (Required): By checking this box, I certify to the best of my knowledge and belief that the information in this application is complete and accurate, I am the legal guardian of the child listed above, and I understand that any false information, omission, or misrepresentation of facts may result in the rejection of this application or future dismissal of the applicant.*

Answer Required

I Agree

Confirmation Email

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