WASHINGTON COLLEGE

STUDENT ACCIDENT & SICKNESS INSURANCE PROGRAM
FOR THE 2016-2017 ACADEMIC YEAR

WAIVER FORM FOR SPRING 2017 STUDENTS


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

The deadline for submitting the waiver form is January 15, 2017.

Asterisk (*) denotes required field

STUDENT INFORMATION
 
first name: *
last name: *
student ID:
date of birth: * (MM/DD/YYYY)