VSP Vision Care
2019-2020 Academic Year

ENROLLMENT FORM

 FOR STUDENTS REGISTERING FALL 2019  

 

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

Asterisk (*) denotes required field

STUDENT INFORMATION

 
 *Note: social security number OR student ID is required.
 (MM/DD/YYYY)

 

Vision Plan Details

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Member SavingsNational Average Cost without Vision Coverage