Gordon-Conwell Theological Seminary
STUDENT HEALTH PLAN

2018 - 2019 Enrollment Form

Fall Term 2018

Returning and New incoming Students for Fall Term 2018 taking 6+ credits at both South Hamilton and Boston should complete this form to confirm and expedite enrollment for the GCTS Student Health Plan for the Fall 2018 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 14, 2018 you will be automatically enrolled in the Student Health Plan with a "Student Only" plan. After September 14, 2018, 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)