Gordon-Conwell Theological Seminary
STUDENT HEALTH PLAN

2016-2017 Annual Waiver Form

Eligible Fall 2016 students taking 6+ credits at South Hamilton (or 9+ credits at Boston) who will have adequate health insurance from September 1, 2016, 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 the DEADLINE of midnight on September 23, 2016, you will be unable to remove the charge on your student account.


This form is for Fall 2016 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)