WORCESTER STATE UNIVERSITY

YES, I WANT TO ENROLL IN THE WORCESTER STATE UNIVERSITY
STUDENT HEALTH INSURANCE PLAN

2018-2019 ACADEMIC YEAR
SPRING SEMESTER


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

PLEASE NOTE: YOUR WORCESTER STUDENT ID# CONSISTS OF 7 DIGITS FOLLOWING 0XXXXXX. IF YOU DO NOT KNOW YOUR ID#, PLEASE CONTACT LAURIE RIESER AT THE BURSAR'S OFFICE AT 508-929-8816.

Asterisk (*) denotes required field

STUDENT INFORMATION

 
first name: *
last name: *
social security number: *
student ID: * (7 digits including leading zeros)
date of birth: * (MM/DD/YYYY)