Gordon-Conwell Theological Seminary
STUDENT HEALTH PLAN

2018 - 2019 Waiver Form

Fall Term 2018

Returning and New incoming Fall 2018 students taking 6+ credits at both South Hamilton and Boston who will have adequate health insurance from September 1, 2018 through August 31, 2019, 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 14, 2018, you will be charged for the Student Health Plan. 


This form is for Returning and New Incoming Fall 2018 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)