8/1/2019
My external transcripts have been evaluated by KCC. Submit your transfer course report from STAR
accessible via the UH Portal (myuh.hawaii.edu).
My external transcripts have not been evaluated by KCC. Submit unofficial copies with this
application, send official copies to the KCC Kekaulike Information & Service Center, complete Online
request for Transcript Evaluation. To complete this form, you must log in with your UH Email
account. Complete this form at: http://go.hawaii.edu/oxG
5.
“My Plan Initiative.” Complete reflection essays and self assessments for your program/career pathway.
6.
Self-addressed, stamped #10 (4 1/8” X 9 1/2") envelope.
APPLICANT CERTIFICATIONS:
I certify that the answers and responses provided for all of the items on this Admissions Application/Check List are true to
the best of my knowledge and belief. I understand that providing incorrect or false information will subject me to the
requirements and/or discipline measures as provided under the University’s Student Conduct Code. I understand that if I
am not accepted into the program of application, I must submit a new application and all required documents for any
subsequent semester. I also allow KISC to change my major and home institution if I am accepted into the CHW program.
I understand that if I am not accepted into the CHW program, my home institution and major will not change.
“Health care students are required to complete University prescribed academic requirements that involve
practice in a University affiliated health care facility setting with no substitution allowable for the
completion required clinical practice. Failure of a student to complete the prescribed clinical practices
shall be deemed as not satisfying academic program requirements. It is the responsibility of the student
to satisfactorily complete any background checks and drug testing that may be required by the affiliated
health care facility to which he/she is assigned for clinical practice in accordance with procedures and
timelines as prescribed by that affiliated health care facility.”
I understand that a criminal background check and drug test may be required for entry into clinical practice. ________
(please initial)
I understand that clinical practice is required for completion of this program. ________ (please initial)
I understand that insufficiently enrolled classes may be deferred until minimum enrollment is met. _______ (please initial)
I understand that priority selection is given to Hawai‘i State residents for tuition purposes and that non-residents will be
considered after all qualified residents have been accommodated per Board of Regents Policy. ________ (please initial)
Print Name ____________________________ Signature ________________________ Date_____________
Kapi‘olani Community College, Health Sciences and Emergency Medical Services Departments
4303 Diamond Head Road, Kauila 106 ♦ Honolulu, Hawai’i 96816-4421 ♦ Telephone: (808) 734-9224
Website: www.kapiolani.hawaii.edu
An Equal Opportunity/Affirmative Action Institution
Health Sciences Department
Application Summary: For office use only
Date Received: _____________________ Application Complete: _____________
Counselor’s Initials: _________________ KCC GPA Verified: _______________
HI Resident: Y N
