Rev 11/15/18
Semester Entering: Year 20___ ___
_Fall _Winter _Spring _Summer
t Attending Classes at:
_HCC _Pearl Harbor Apprenticeship
_SOCAD _Other __________________
(Please print clearly)
School ID #
(if no ID#)
Last Name, First Name MI
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 CenterConfidential 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).
tact Person on Oahu (preferably)
Home Phone
Work Phone #
Cellular/Beeper #
Name of y
our physician
Clinic or location of Physician
Medical Ins
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.
Submitted by (Signature)
~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ FOR OFFICE USE ONLY ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~
__ SPAEMRG Incomplete:__Student advised _ _Called __Msg left __Postcard/comp Other:________________________
Clear Form
These services are available for qualified students…
Student ACCESS
Contact us early!!! You may be eligible to receive services such as those listed below.
Documentation of your disability is required. Because the process of acquiring proper documentation can take some
time, it is recommended that you submit your documentation as early as possible before the semester begins. Late
submissions will delay your services and may require a postponement of certain services to the next appropriate semester.
Contact us at (808) 844-2392 or 845-9272 (voice/text), 844-2391(fax) or Email accesshcc-l@lists.hawaii.edu
Visit our website at: http://honolulu.hawaii.edu/disability for additional information.
Accommodation Type
Timeline for Requests (minimum)
Required Items to Submit
Sign language interpreters for courses
6-8 weeks in advance of course start date
Course, lab, and field trip schedule and location
Sign language interpreter for extra-
curricular events or activities
10 days in advance of activity date
Event schedule and location
Textbooks into audio-tape format
6-8 weeks in advance of course start date
Copy of textbook and course syllabus
Textbooks into Braille format
1 semester in advance of course start date
Copy of textbook and course syllabus
Handouts into audio-tape format
10 days
Copy of handouts
Handouts into Braille format
2-4 weeks depending on complexity of
Copy of handouts
Classroom relocation
2 weeks in advance of course start date
Course schedule and location
Notetakers for courses
2-3 weeks
Course schedule and location
Testing accommodations
1 week in advance of test date
Instructor name, course name, test date and
time, materials or equipment needed
Specific accommodations not listed
Determined on a case-by-case basis so
earliest possible notice is recommended
Determined on a case-by-case basis
~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~
Welcome to Honolulu Community College's
Wellness Center
Live well, be well, do well, and love well
Phone (808) 845-9180 Email: hccwell@hawaii.edu
The Wellness Center provides free confidential personal counseling and support services to help students manage personal life issues
and navigate their college experience. In addition, the office also provides outreach and educational services to the campus community
in the context of mental health and wellness and violence prevention.
Counseling services include:
Short term counseling
Crisis counseling
Referrals to community agencies
Come learn more about how to stay well and balance your life with your college experience.
Visit the website via clicking on the HCC website: “honolulu.hawaii.edu “> “Services for Students” page then go to list under “Other
Resources”> Wellness Center
Contact me anytime for more information at:
Phone: (808) 845-9180
Email: hccwell@hawaii.edu