Fillable Application Period: December 1 March 1 This application (Kapiolani Community College)

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Application Period: December 1 March 1 This application (Kapiolani Community College)

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4/5/2019
Health Sciences Department
Application Period: December 1 – March 1
This application is intended for students who have completed the KapCC CA in Medical Assisting, but did not
immediately continue on to the Associate in Science degree.
Directions: Please complete each item carefully typewritten or neatly printed, and submit this Admission Application
Checklist and all required documents to a Health Sciences Counselor during walk-in counseling hours. If the application
deadline falls on a weekend or recognized holiday, applications will be accepted on the following business day. Only
this completed program Admission Application including supplemental documentation submitted to the Health
Career Counseling Center (Kauila 106) by the appropriate deadline will be accepted for processing. Applications
must be submitted in person during walk-in counseling only.
APPLICANT INFORMATION
Name: UH Number/Username
Last Name First Name M.I.
Mailing
Address:
Street / POB City State Zip Code
Phone:
Cell Home Work
UH SYSTEM Email Address:
List other name(s) used on documents:
(Notify the KCC Kekaulike Information & Service Center regarding other names used on college documents.)
ADMISSION APPLICATION CHECKLIST FOR MEDA PROGRAM
1. Attend a Mandatory MEDA Program Information Session within one year of your application submission.
For more information visit www.kapiolani.hawaii.edu or pick up an Information Session schedule from Kauila
122 or Kauila 106 during normal business hours.
Date Attended: _______/_______/_______ (Month / Day / Year)
2. Complete the online UH System Application if you are not currently enrolled at any UH System institution
during the semester you submit your application. (http://apply.hawaii.edu)
3. Complete KapCC Certificate in MEDA prior to the end of the application period
4. College transcripts for courses completed within the University of Hawai‘i System. Print out
student copy of unofficial transcripts for all course work WITHIN the UH System and highlight all
prerequisite/qualification courses. UH system transcripts are downloadable from the UH Portal
(myuh.hawaii.edu
).
5. College transcripts for courses completed outside of the University of Hawai‘i System.
If transferring courses from institutions outside the UH System, please list the institution and when your transcript
was requested:
• Institution: ___________________________ Transcript Request Date: ___________
• Institution: ___________________________ Transcript Request Date: ___________
• Institution: ___________________________ Transcript Request Date: ___________
Kapi`olani Community College Admission Application Checklist
MEDICAL ASSISTING PROGRAM
Associate in Science
4/5/2019
Health Sciences Department
My external transcripts have been evaluated by KCC. Submit your transfer course report from STAR
accessible via the UH Portal (myuh.hawaii.edu).
My external transcripts have not been evaluated by KCC. Submit unofficial copies with this
application, send official copies to the KCC Kekaulike Information & Service Center, complete Online
request for Transcript Evaluation. To complete this form, you must log in with your UH Email
account. Complete this form at:
http://go.hawaii.oxG
6. “My Plan Initiative.” Complete self-assessments.
7. Self-addressed, stamped #10 (4 1/8” X 9 1/2") envelope.
APPLICANT CERTIFICATIONS:
I certify that the answers and responses provided for all of the items on this Admission Application are true to the best of
my knowledge and belief. I understand that providing incorrect or false information will subject me to the requirements
and/or disciplinary measures as provided under the Student Conduct Code. I understand that if I am not accepted into the
program of application, I must submit a new application and all required documents for any subsequent semester. I also
allow KISC to change my major and home institution if I am accepted into the MEDA program. I understand that if I am
not accepted into the MEDA program, my home institution and major will not change.
“Health care students are required to complete University prescribed academic requirements that involve practice
in a University affiliated health care facility setting with no substitution allowable for the completion required
clinical practice. Failure of a student to complete the prescribed clinical practices shall be deemed as not
satisfying academic program requirements. It is the responsibility of the student to satisfactorily complete any
criminal background checks and drug testing that may be required by the affiliated health care facility to which
he/she is assigned for clinical practice in accordance with procedures and timelines as prescribed by that affiliated
health care facility.”
I understand that a criminal background check and drug test may be required for entry into clinical practice. ________
(please initial)
I also understand that clinical practice is required for completion of this program. ________ (please initial)
I understand that priority selection is given to Hawai‘i State residents for tuition purposes and that non-residents will be
considered after all qualified residents have been accommodated per Board of Regents Policy. ________ (please initial)
Print Name ____________________________ Signature ________________________ Date_____________
4/5/2019
Health Sciences Department
SAMPLE of how to complete the application:
These are the requirements
Fill in the information about the class you took to meet each requirement
Required before application
deadline
Test Score
OR Course
Alpha
Term of
Completion
Institution
Grade/Credit
Qualification for Math 32 or higher
Math 100 Spring 2016 LCC A/3.0
Qualification for ENG 100 Placement into
ENG 100
Date of Test:
1/12/2016
Accuplacer, KCC Testing
Center
N/A
Qualification
Requirement
Institution
Semester & Year
of Graduation
Points
College Certificate of
Achievement in Medical
Yes No
3 0
Current CMA
Certification (AAMA)
Yes No
3 0
Total
prerequi
site
points
(required
for
admission)
_____ / 6
4/5/2019
Health Sciences Department
A.S. Degree General Education Requirement Support courses are not required for admission, however,
students who have completed them can earn additional points on the application. If you have completed
program support courses, please enter them below:
Education
Requirements
(Program Support
Courses)
* not required for
Course
Alpha
Term of
Completion
Institution
Name
Grade/
Credits
Points
ENG 100 Composition I
Yes
No
1 0
MATH 100 Survey of
Mathematics (3) OR
Yes No
1 0
FAMR 230 Human
Growth & Development
A B C
3 2 1
Anatomy & Physiology I
A
B C
3 2 1
PHYL 141L Human
Anatomy & Physiology I
A B C
3 2 1
A. S. Humanities
elective (100 level or
A B C
3 2 1
Total support points
___/14
Kapi‘olani Community College, Health Sciences and Emergency Medical Services Departments
4303 Diamond Head Road, Kauila 106 ♦ Honolulu, Hawai’i 96816-4421 ♦ Telephone: (808) 734-9224
Website: www.kapiolani.hawaii.edu
An Equal Opportunity/Affirmative Action Institution
Application Summary: For office use only
Date Received: _____________________
Counselor’s Initials: _________________ Application Complete: _____________
HI Resident: Y N
KCC GPA Verified: _______________
3/25/2019
The purpose of the My Plan Self-Assessment is a counseling tool for prospective healthcare majors to
identify and better understand your career pathway including your strengths and areas of focus. Working in
healthcare requires a combination of academic and professional knowledge and skills and a commitment to
public service. As you plan, find ways to make your strengths shine and to improve your weaker areas. Please
complete areas of this self-assessment by marking the boxes. All response are voluntary. Consider discussing
your self-assessment with a counselor/advisor to understanding how they support your academic and career
goals.
Knowledge of the Profession
Below
Expectations
Meets
Expectations
Exceeds
Expectations
Identif
ied career goals in my health pathway
Identified career alternatives in my health pathway
Relevant experience – by volunteer experiences
Relevant experience – by servicing learning experiences
Relevant public service – by paid work experiences
Understand “professional qualities” of health pathway(s)
Understanding of current healthcare issues
Comfort with bodily fluids or personal patient care
Comfort with illness
Comfort with injury
Comfort with death
Comfort with physical contact with people
Ability to multitask and adapt to change
Ability to accept constructive feedback
Ability to handle occupational crises, challenges or problems
Ability to move forward to achieve the goals and outcomes
Ability to follow safety guidelines and standards of practice
Personal Characteristics
Below
Expectations
Meets
Expectations
Exceeds
Expectations
Demonst
rate commitment to public service
Demonstrate empathy/altruism
Demonstrate moral/ethical integrity
Demonstrate emotional maturity
Demonstrate good interpersonal relationships
Accept responsibility
Ability to work independently to achieve the goal/task
Collaborate and teamwork to achieve the goal/task
Accept and demonstrate leadership
Be dedicated/hard-working healthcare practitioner
Committed to life-long learning
Kapi`olani Community College
MY PLAN
Self – Assessment
Health Sciences Department
Reset
3/25/2019
Academic Strength
Below
Expectations
Meets
Expectations
Exceeds
Expectations
+Completed prerequisites of health program of study
+Completed support courses of health program of study
Achieved minimum cumulative GPA for program entry
Achieved prerequisite course GPA for your program entry
Effective verbal and nonverbal communication skills
Ability to utilize technology effectively for learning
Established Support Systems to Succeed in
Health Pathway Program
Below
Expectations
Meets
Expectations
Exceeds
Expectations
Established support for transportation to externships
Established support for financial assistance prior to entry
Established support for nonacademic responsibilities
Established support for personal and time management skills
Established support for continuous professional learning
Established opportunities to balance personal, family, & school
Established support for campus and community resources
+A
s required for program entry and graduation or meet other requirements as directed for program admissions.
An
Equal Opportunity/Affirmative Action Institution
Kapi`olani Community College
MY PLAN
Self-Assessment
The University of Hawai‘i does not discriminate on the basis of race, sex, age, color, national origin, or disability. For
inquiries regarding our nondiscrimination policies, please contact the Kapiolani Community College designees:
Kelli Brandvold, ADA Coordinator for Employees and EEO/AA Campus Coordinator
Office: ‘Ilima 208
(808) 734-9575; kellib@hawaii.edu
Deneen Kawamoto, ADA Coordinator for Students Office: ‘Ilima 107
(808) 734-9522; deneenk@hawaii.edu
UHCC offers Career and Technical Education (CTE) Programs of Study leading to Associate of Science (AS) and
Associate of Applied Science (AAS) degrees, as well as postsecondary certificates, in career fields such as arts and
communications, business, health careers, industrial and engineering technology, natural resources, and public and
human services.
For more information, visit our website at http://uhcc.hawaii.edu/programs/index.php
.
UHCC applies an open access policy, with program admission based upon the completion of applicable course/testing
prerequisites. The lack of English skills will not be a barrier to admission and participation in CTE programs.
Health Sciences Department
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Application Period: December 1 March 1 This application (Kapiolani Community College)

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Completed 25 July 2020

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