Poplar Bluff Technical Career Center Application for Admission - Secondary Programs
3203 Oak Grove Road
Poplar Bluff, MO 63901
573-785-2248 573-785-4168 (fax)
573-785-6683 School of Cosmetology
573-785-7751 Mules Café Extension Campus -
1110 N Westwood Blvd, Poplar Bluff, Missouri 63901

Return this completed application and the appropriate other materials. Completion of this application does not constitute admission to the program of study for which applicant is applying.
Email address *
Perspective Students
Prospective students should review the programs they are interested in by scheduling shadowing or talking with sending school counselors and/or TCC staff. Applications must be completed in full for students to be considered for enrollment in a PBTCC Program.
Part 1 Personal Information
Last Name *
Your answer
First name *
Your answer
Middle name *
Your answer
Street Address *
Your answer
City *
Your answer
Zip Code *
Your answer
High School Currently Attending
Guardian FIRST Name *
Your answer
Guardian LAST Name *
Your answer
Relationship to student
Telephone - Home *
Your answer
Telephone - Cell
Your answer
Telephone - Work
Your answer
Guardian's email for school correspondence (must be a valid email) write N/A or copy other guardians in this box if they do not use email
Your answer
Guardian FIRST Name
Your answer
Guardian LAST Name
Your answer
Relationship to student
Telephone - Home
Your answer
Telephone - Cell
Your answer
Telephone - Work
Your answer
Guardian's email for school correspondence (must be a valid email) write N/A or copy other guardians in this box if they do not use email
Your answer
Student's Date of Birth *
MM
/
DD
/
YYYY
Student's Social Security Number *
Your answer
Does student use language other than English? If so, what language: *
Part 2 Program Choice (clearly indicate the desired program of study)
Requires a commitment to the entire program (one year or two year).
Program Choice *
Part 3 Emergency Information
In Case of Emergency, Please Notify (FULL NAME) *
Your answer
Emergency Contact Relationship to student *
Emergency Contact Address (MUST include city, state and zip code) *
Your answer
Emergency Contact Home/Cell Phone *
Your answer
Emergency Contact Work Phone
Your answer
List any medical conditions PBTCC staff should be aware of: *
Your answer
Gender *
Ethnic Description *
Signature Statement
With my signature I certify that all information provided is to the best of my knowledge true and complete and I have not willingly or knowingly withheld information. I understand I could be withdrawn from a program/class should enrollment information be inaccurate or incomplete.
By electronically signing this I authorize Poplar Bluff Technical Career Center and Poplar Bluff R-1 Schools staff to use their discretion regarding emergency procedures. I also realize this is a long term commitment, which means I can not change this course at Semester. I am signing up to take the entire program and I understand those requirements. (Signify agreement by writing your name) *
Your answer
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