MGH INSTITUTE OF HEALTH PROFESSIONS
Student Health Insurance Plan

2017-2018 Fall Term Enrollment Form

This enrollment form is for New and Returning Degree/Certificate Students for the Fall 2017 Term.

The enrollment deadline date for Fall Semester is August 31, 2017.


(Enrollment Period of 09/01/17-04/30/18)

NOTE:  If you will graduate in September of 2017, this coverage will be effective until August 31, 2017.  If you will graduate in January of 2018, this coverage will be effective until December 31, 2017.

 

Asterisk (*) denotes required field

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