VSP Vision Care
2017-2018 Academic Year

ENROLLMENT FORM

 FOR STUDENTS REGISTERING SPRING 2018  

The enrollment deadline for the VSP Vision Care Plan has been extended until 1/15/18. Any student who enrolls from 12/16/17 to 1/15/18 will have an effective date of 2/1/18. 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)