CLARK UNIVERSITY
STUDENT HEALTH INSURANCE PLAN

2016-17 POLICY YEAR
​SPRING WAIVER FORM

This form is for eligible students enrolled in the Spring 2017 semester.


TO CONTINUE THE WAIVER PROCESS, PLEASE FILL OUT THE REQUIRED FIELDS BELOW:

Asterisk (*) denotes required field

STUDENT INFORMATION
 
first name: *
last name: *
social security number:
student ID: * Your Clark ID number begins with "C" followed by eight digits.