EASTERN NAZARENE COLLEGE
STUDENT HEALTH INSURANCE PLAN

2017-18 POLICY YEAR

TRADITIONAL UNDERGRADUATE STUDENTS
SPRING TERM WAIVER FORM

ALL STUDENTS MUST COMPLETE EITHER A WAIVER FORM OR ENROLLMENT FORM FOR THE SPRING TERM 2018.
TRADITIONAL UNDERGRADUATE STUDENT DEADLINE DATE:  January 30, 2018

This form is for all new incoming students enrolled in the Spring 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)