Gordon-Conwell Theological Seminary
STUDENT HEALTH PLAN

Spring 2017 Waiver Form

Newly eligible Spring 2017 students taking 6+ credits at South Hamilton (or 9+ credits at Boston) who will have adequate health insurance from January 15, 2017, through August 31, 2017, can submit this waiver form to opt out of the Student Health Plan.

If you do not complete this waiver form by midnight on February 10, 2017, you will be charged for the Student Health Plan. If you do not complete this waiver form by midnight on February 24, 2017, you will be unable to remove the charge on your student account.


This form is for Spring 2017 students who are newly eligible
for the Student Health Plan.


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)