VSP Vision Care
2018-2019 Academic Year

ENROLLMENT FORM

 FOR STUDENTS REGISTERING FALL 2018  

The enrollment deadline for the VSP Vision Plan has been extended until 10/15/18.   Any student who enrolls from 9/16/18 to 10/15/18 will be effective as of 11/1/18.  The premium is not pro-rated. 

 

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)