WASHINGTON COLLEGE

STUDENT ACCIDENT & SICKNESS INSURANCE PROGRAM
FOR THE 2016-2017 ACADEMIC YEAR

ENROLLMENT FORM FOR STUDENTS REGISTERING FOR SPRING 2017


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

The deadline for submitting the enrollment form is January 15, 2017.

Asterisk (*) denotes required field

STUDENT INFORMATION
 
first name: *
last name: *
social security number: *
student ID: *
date of birth: * (MM/DD/YYYY)