CLARK UNIVERSITY
STUDENT HEALTH INSURANCE PLAN

2018-2019 POLICY PERIOD
SPRING ENROLLMENT FORM


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

Asterisk (*) denotes required field

STUDENT INFORMATION

 
first name: *
last name: *
student ID: * Your Clark ID number begins with "C" followed by eight digits.
date of birth: * (MM/DD/YYYY)