VSP Vision Care
2018-2019 Academic Year

ENROLLMENT FORM

 FOR STUDENTS REGISTERING SPRING 2019  

 

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

Asterisk (*) denotes required field

STUDENT INFORMATION

 
first name: *
last name: *
 *Note: social security number OR student ID is required.
social security number:
student ID:
date of birth: * (MM/DD/YYYY)

 

Vision Plan Details

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Member SavingsNational Average Cost without Vision Coverage