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Johnson & Wales University
STUDENT HEALTH INSURANCE PLAN

Medical Withdrawal Enrollment Form
2025-2026 Academic Year

A student can enroll in the student health insurance plan when withdrawn for medical reasons for a maximum of one semester if the student was enrolled in the student health insurance plan in the prior semester. At the time of withdrawal, the student must intend to return to Johnson & Wales University and remain a degree-seeking candidate.

Asterisk (*) denotes required field

STUDENT INFORMATION

 (MM/DD/YYYY)