EASTERN NAZARENE COLLEGE
STUDENT HEALTH INSURANCE PLAN

2018-19 POLICY YEAR

TRADITIONAL UNDERGRADUATE STUDENTS
ANNUAL TERM WAIVER FORM

ALL STUDENTS MUST COMPLETE EITHER A WAIVER FORM OR ENROLLMENT FORM FOR THE FALL TERM 2018.
TRADITIONAL UNDERGRADUATE STUDENT DEADLINE DATE:  September 21, 2018

This form is for all returning and new incoming students enrolled in the Fall 2018 semester.


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

Asterisk (*) denotes required field

STUDENT INFORMATION

 
first name: *
last name: *
student ID: *
date of birth: * (MM/DD/YYYY)