Emmanuel College
SPRING UNDERGRADUATE
​STUDENT HEALTH INSURANCE PLAN

Spring Enrollment Form For NEW Spring Students Only
2017-2018 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)