Fillable Honcc Emergency Contact Form printable pdf download

Rev 7/31/13

HonCC EMERGENCY CONTACT FORM

Semester Entering: Year 20___ ___

Fall

Winter

Spring

Summer

ROUTE TO HCC HEALTH OFFI CE – BLDG. 2, RM . 108A

Student Attending Classes at:

HCC

Pearl Harbor Apprenticeship

SOCAD

Other __________________

____________________________________________________

____________________ ___/___/19___

Last Name,

First Name

School ID #

Birthdate

(Please print clearly)

Instructions:

1. Either submit this form OR go online to submit/update your information each semester or as needed:

Students may submit completed form directly to HCC Health Office, 874 Dillingham Blvd. Bldg. 2,

Rm 108A, Honolulu, HI 96817 or FAX (808) 847-9836. 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–

You are invited to go to your MyUH Portal account (Log in and Click on “Student

Records”>”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

from the HCC Health Office website (see #5 below) & return it electronically. Please update this

Form

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://

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

for more information and

important service request timelines.

Mental Health & Wellness Services (MHWS) – Confidential counseling & referral service for registered

students is available. Contact (808) 845-9180, email gallantk@hawaii.edu, or visit

for more information on this service.

Visit

for emergency contact form, health insurance, resources & other

valuable information. Questions? Call the HCC Health Office at (808) 845-9282 (voice/text).

EMERGENCY CONTACT INFORMATION

______________________________________________________

__________________________

Contact Person on Oahu (preferably)

Relationship

______________________

_______________________

__________________________

Home Phone #

Work Phone #

Cellular/Beeper #

_____________________________________________________

__________________________

Name of your physician

Clinic or location of Physician

_____________________________________________________

__________________________

Medical Insurance

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, & MHWS 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 MHWS to receive counseling & referral services. By signing below I

agree to these terms and conditions.

____________________________________________________________

____________________

Submitted by (Signature)

Date

~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ FOR OFFICE USE ONLY ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~

__ SPAEMRG Incomplete:__Student advised _ _Called __Msg left __Postcard/comp

Other:________________________

Z:Health_OfficeFormsEmergency Contact FormEmergency Contact Info admissions 10-11-12 page 1.doc 7/31/2013

Honcc Emergency Contact Form

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