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
