Fillable STUDENT IDENTIFICATION CARD/KAULANA BUS PASS (Kauai Community College)

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STUDENT IDENTIFICATION CARD/KAULANA BUS PASS (Kauai Community College)

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STUDENT IDENTIFICATION CARD/KAULANA BUS PASS
● Application information is confidential and will not be distributed to any entity.
● Only current students registered in full time or part-time status are eligible to apply for an
ID Card. Non-Credit students are not eligible.
FIRST NAME:
CURRENT MAJOR:
PHONE CONTACT:
May we send you information on upcoming student events?
☐ Yes ☐ No
STAFF INPUT ONLY:
☐ New/Continuing/Returning – 1
st
Card Free
☐ Faculty/Staff - $15 Fee
☐ Lost, Stolen, Replacement Card - $15 Fee
LAST NAME:
UH ID NUMBER: (tuition receipt or MyUH Portal in My Profile)
E MAIL ADDRESS:
HAIR COLOR:
EYE COLOR:
TYPE OF IDENTITY VERIFICATION USED:
☐ State of Hawaii Driver’s License
☐
State of Hawaii Identification Card
☐ High School Identification Card
☐ United States of America Passport
☐
Other Source: ______________________________________
TYPE OF TUITION PAYMENT VERIFICATION USED:
☐ Tuition Receipt ☐ FAFSA Letter ☐ MyUH Portal Verification
☐ Official Waialeale Letter ☐ Other Source: ___________________________________________
DATE COMPLETED
SIGNATURE OF ID MAKER
DATE PICKED UP
NOTICE: Kauai CC Identification/Bus Pass Card is not transferable and shall be forfeited if used by another person. The ID Card
must be presented for re-validation at the end of the expiration period noted on the front of the ID card. Report lost/stolen card
immediately to Campus Center, Rm. 203. A replacement fee of $15 will be assessed. Kauai CC student identification card is valid
for unlimited rides on the Kauai Bus through the following semester dates.
Semester Activation Date Expiration Date
Spring 2020 January 1, 2020 May 31, 2020
Fall 2020 August 1, 2020 December 31, 2020
Spring 2021 January 1, 2021 May 31, 2021
Fall 2021 August 1, 2021 December 31, 2021
(Revised by JC - 01/20)
___________________________________________________________ _______________________________________________
STUDENT LIFE CENTER
Rules and Regulations Contract
1. No profanity, violence or harassment.
2. No “Horse Playing” allowed.
3. No vaulting or jumping on or over furniture (tables, chairs, equipment etc.)
4. No sitting on gaming equipment (pool tables, pin pong table etc.)
5. Return all furniture to their original positions when not in use.
6. Always throw away all wastes in designated trash bins and keep area clean at all times.
7. Always recycle all HI5 bottles and cans and place in designated recycle bins.
8. The Student Life Office and other program offices are prohibited to the general public.
9. Gum chewing, illegal drugs, alcohol and smoking are prohibited at all times.
10. Do not place dirty feet, shoes or slippers on furniture.
11. Any form of gambling is prohibited.
12. Food and beverage items must be consumed in designated areas of the center.
13. Skateboards, scooters or bicycles are not allowed in the Student Life Center.
14. Before signing out to borrow any Student Life equipment, all users must submit a University of
Hawaii ID card and a driver’s license or state ID card. Cards will be held until all gaming
equipment are returned.
15. Once equipment is returned, the staff on duty will check the space and inspect equipment for any
damages. If any damages are confirmed and cited, than user will be held liable for the
replacement or monetary compensation of damaged item(s).
I _____________________________________________________________________ hereby agree to observe the rules and
regulations listed above. Any violation and/or damages cited by Student Life Center staff may advocate for
the forfeiture of my right to utilize the Student Life Center.
Signer of this contract will be held accountable and responsible for any damages incurred.
SIGNATURE:
DATE:
Verified by:
Staff on Duty Signature Date
(Revised by JC - 01/20)
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STUDENT IDENTIFICATION CARDKAULANA BUS PASS (Kauai Community College)

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Completed 25 July 2020

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