Gordon-Conwell Theological Seminary
STUDENT HEALTH PLAN

Annual 2015-2016 Enrollment Form

New and newly eligible students taking 6+ credits at South Hamilton (or 9+ credits at Boston) should complete this form to confirm and expedite enrollment for the GCTS Student Health Plan for the 2015-2016 Policy Year. Dependent coverage may also be elected using this form.

If you do not complete this enrollment form by the FINAL DEADLINE of midnight on October 9, 2015, you will be automatically enrolled in the Student Health Plan with a "Student Only" plan. After October 9, 2015, you will not be able to add a dependent to your plan during this academic year unless your dependent has experienced a qualifying event.


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

Asterisk (*) denotes required field

STUDENT INFORMATION
 
student ID: *
first name: *
last name: *
date of birth: * (MM/DD/YYYY)
last 4 digits of social security number: