Gordon-Conwell Theological Seminary
STUDENT HEALTH PLAN

Annual Term 2017 - 2018 Waiver Form

New and Returning eligible Fall 2017 students taking 6+ credits at South Hamilton (or 9+ credits at Boston) who will have adequate health insurance from September 1, 2017 through August 31, 2018, can submit this waiver form to opt out of the Student Health Plan.

If you do not complete this waiver form by midnight on September 15, 2017, you will be charged for the Student Health Plan. 


This form is for New and Returning Fall 2017 students who are 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)