Gordon-Conwell Theological Seminary
STUDENT HEALTH PLAN

Annual Term 2017 - 2018 Enrollment Form

New and Returning Students for Fall Term 2017 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 2017 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 15. 2017 you will be automatically enrolled in the Student Health Plan with a "Student Only" plan. After September 15, 2017, 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)