Hawai’i Community College
Hā‘awi Kōkua Program Services for Students with Disabilities and Academic Challenges
INTAKE FORM FOR STUDENT WITH A DISABILITY
*The student who will attend Hawai’i Community College must complete this form.
1. Name: _____________________________________________________________________________
Last First Middle Initial
2. Mailing Address: _____________________________________________________________________
Street City State Zip Code
3. E-mail Address: ______________________________________________________________________
4. Telephone: (home) ___________________ (work) __________________ (cell) ___________________
5. Emergency contact: __________________________________________________________________
Name Phone Number
6. Date of Birth: __________________ 7. Male: ____ Female: ____ 8. Marital Status: _______________
9. Ethnicity: ___________________________________________________________________________
10. Disability: _________________________________________________________________________
*(Documentation of the disability is required to receive services)
Is the disability temporary? (Explain) _______________________________________________________
_____________________________________________________________________________________
Onset date of disability: _________________________________________________________________
11. Explain limitations resulting from the above disability: ______________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
12. Medications: ______________________________________________________________________
Effects of Medication: ___________________________________________________________________
13. Medical Doctor: ____________________________________________________________________
Name Address Phone Number
Other Doctor: _________________________________________________________________________
Name Address Phone Number
May we contact these doctors? ___________________________________________________________
Rev. 22-Apr-13
14. Explain how your disability could affect your academic performance: __________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
15. What High School did you attend? ______________________________________________________
Do you have a high school? Diploma ____________ GED ____________ Certificate ____________
Were you in any Special Education Classes? _________________________________________________
Describe the accommodations made for you in high school? ____________________________________
_____________________________________________________________________________________
Special equipment provided: _____________________________________________________________
16. What challenges or problems occurred while you were in high school? ________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
17. What challenge may occur in the college classroom? _______________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
18. What challenges may occur here at HawCC campus? _______________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
19. Please identify areas where you have the most challenges:
Reading _____ Writing _____ Hearing _____ Speaking _____ Transporting _____ Testing _____
20. What is your base of knowledge of Adaptive Technology or Assistive Devices? __________________
_____________________________________________________________________________________
_____________________________________________________________________________________
21. List any Specialized Support Services you receive from other agencies? ________________________
_____________________________________________________________________________________
Rev. 22-Apr-13
22. Explain your vocational goal with this agency? ____________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
23. What information would you like this program to share with your instructor? ___________________
_____________________________________________________________________________________
_____________________________________________________________________________________
24. What information are you willing to discuss with your instructors? ____________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
25. What other challenges do you currently have, that may create a difficult time in school? __________
_____________________________________________________________________________________
_____________________________________________________________________________________
I understand that the above information is protected under the Family Educational Rights and Privacy
Act of 1974, within the Hawai’i Community College.
Student Signature: __________________________________________ Date: ______________________
Rev. 22-Apr-13
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