Emmanuel College
ANNUAL UNDERGRADUATE
​STUDENT HEALTH INSURANCE PLAN

Annual Enrollment Form 
2018-2019 Academic Year


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

Asterisk (*) denotes required field

STUDENT INFORMATION

 
first name: *
last name: *
student ID: *
date of birth: * (MM/DD/YYYY)