EASTERN NAZARENE COLLEGE
STUDENT HEALTH INSURANCE PLAN

2018-19 POLICY YEAR

TRADITIONAL UNDERGRADUATE STUDENTS

ANNUAL TERM ENROLLMENT FORM

This form is for all returning and new incoming students enrolled in the Fall 2018 semester.

 

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

Asterisk (*) denotes required field

STUDENT INFORMATION

 
first name: *
last name: *
student ID: *
date of birth: * (MM/DD/YYYY)