HonC
C EM
ERG
ENC
Y CO
N
TA
CT F
ORM
ROUTE TO HCC HEALTH OFFICE – BLDG. 2, RM. 108A
Rev 11/15/18
Semester Entering: Year 20___ ___
_Fall _Winter _Spring _Summer
Studen
t Attending Classes at:
_HCC _Pearl Harbor Apprenticeship
_SOCAD _Other __________________
____________________________________________________
(Please print clearly)
________________
School ID #
(preferred)
___/___/19___
Birthdate
(if no ID#)
Last Name, First Name MI
Instructions:
1. Either submit this form OR go online to submit/update your information each semester or as needed:
o Students may submit completed form directly to HCC Health Office, 874 Dillingham Blvd. Bldg. 2, Rm 108A,
Honolulu, HI 96817 or FAX (808) 441-5329. Military SOCAD & Pearl Harbor Apprenticeship students may turn
in document to their respective HCC base office. Forms submitted to our office will be inputted electronically &
destroyed (please read on for update info). –OR–
o You are invited to go to your MyUH Portal account (Log in and Click on “Student Services Menu”>”Personal
Information” tab on top > “View/Update My Emergency Contacts” to add and update your emergency contact
information) -- OR -- you may download the HonCC Emergency Contact Form from the HCC Health Office website
(see #5 below) & return it electronically. Please update this important information at least each semester or
when names & phone numbers change.
2. Sign up for Emergency Alerts (i.e. campus closures, etc.)--Go to your MyUH Portal account > Click on “My Profile”
tab>Select the UH Alert Emergency Notification image or by visiting https://www.hawaii.edu/alert/.
3. Disability Services - If you have a disabling condition and require assistance, contact
Student ACCESS at (808) 844-2392 (voice/text) or 845-9272 (voice/text),
email accesshcc-l@lists.hawaii.edu, or visit www.honolulu.hawaii.edu/disability
for more information and important service
request timelines.
4. Wellness Center – Confidential personal counseling & referral service for registered students are available. Contact (808)
845-9180, email hccwell@hawaii.edu, or visit http://honolulu.hawaii.edu/mentalhealth/ for more information on this service.
5. Visit www.honolulu.hawaii.edu/health for emergency contact form, health insurance, resources & other valuable
information. Questions? Call the HCC Health Office at (808) 845-9282 (voice/text).
EMERGENCY CONTACT INFORMATION
______________________________________________________
Con
tact Person on Oahu (preferably)
__________________________
Relationship
______________________
Home Phone
#
_______________________
Work Phone #
__________________________
Cellular/Beeper #
_____________________________________________________
Name of y
our physician
__________________________
Clinic or location of Physician
_____________________________________________________
Medical Ins
urance
__________________________
Physician’s Phone #
I am aware that the emergency information that I provide is made available to staff involved with emergencies through the UH
System’s electronic student information system. Updates may be made directly through my personal MyUH account or by contacting
the Health Office. Information that I provide to the Health Nurse, Student ACCESS, & Wellness Center regarding any special health
condition or disability will be kept confidential except in emergency situations on a need-to-know basis. I am responsible for contacting
Student ACCESS to request & receive disability accommodations and/or the Wellness Center to receive counseling & referral services.
By signing below I agree to these terms and conditions.
X____________________________________________________________
Submitted by (Signature)
____________________
Date
~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ FOR OFFICE USE ONLY ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~
__ SPAEMRG Incomplete:__Student advised _ _Called __Msg left __Postcard/comp Other:________________________
11/16/2018
