VSP Vision Care
2019-2020 Academic Year

ENROLLMENT FORM

 FOR STUDENTS REGISTERING FALL 2019  

The enrollment deadline for the VSP Vision Plan has been extended until 9/15/19.  Any student who enrolls from 8/16/19 to 9/15/19 will be effective as of 10/1/19.  The premium is not pro-rated.

 

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)