Gordon-Conwell Theological Seminary
STUDENT HEALTH PLAN

2016-2017 Annual Enrollment Form

Eligible Fall 2016 students taking 6+ credits at South Hamilton (or 9+ credits at Boston) should complete this form to confirm and expedite enrollment for the GCTS Student Health Plan for the Fall  2016 Semester. Dependent coverage may also be elected using this form.

If you do not complete this enrollment form by the DEADLINE of midnight on September 23, 2016, you will be automatically enrolled in the Student Health Plan with a "Student Only" plan. After September 23, 2016, you will not be able to add a dependent to your plan during this academic year unless your dependent has experienced a qualifying event.


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

Asterisk (*) denotes required field

STUDENT INFORMATION
 
first name: *
last name: *
social security number:
student ID: *
date of birth: * (MM/DD/YYYY)