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CLARK UNIVERSITY
STUDENT HEALTH INSURANCE PLAN

2024-2025 POLICY YEAR
SPRING WAIVER FORM


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

Please note that your student ID must contain C + 8 digits (example: C70123456)

Asterisk (*) denotes required field

 (MM/DD/YYYY)