Gordon College
STUDENT HEALTH INSURANCE PROGRAM

ANNUAL ENROLLMENT FORM
2017-2018 Academic Year

THIS FORM IS FOR STUDENTS ENROLLING IN THE SHIP FOR THE FIRST TIME STARTING WITH THIS 1718 POLICY.


 

TO CONTINUE THE ENROLLMENT PROCESS, PLEASE FILL OUT THE REQUIRED FIELDS BELOW:

Asterisk (*) denotes required field

STUDENT INFORMATION
 
first name: *
last name: *
social security number: *
student ID: *
date of birth: * (MM/DD/YYYY)